LIBRARY OF CONGRESS. 



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UNITED STATES OF AMERICA. 



A TREATISE 



ON 



HEADACHE AND NEURALGIA, 



INCLUDING 



SPINAL IRRITATION AND A DISQUISITION 
ON NORMAL AND MORBID SLEEP. 



/ 
BY 



J. LEONAED COmsriNG, M.A., M.D., 

Consultant in Nervous Diseases to St. Francis Hospital ; FeUow of the New 
York Acaderav of Medicine ; Member of the New York 
Neurological Society ; etc. 

AUTHOR OF 

"A Treatise on Hysteria and Epilepsy,'^ " Local Anaesthesia^^ " Brain Rest," etc. 
WITH AN APPENDIX. 

Eye Strain, a Cause of Headache, 
By DAYID WEDSTEE, M.D., 

Prof of Ophthalmology in the New York Polyclinic ; Surgeon to the Manhat- 
tan Eye and Ear Hospital, etc., etc. 



ILLUSTRATED. 



THIRD ^Z)/r/OA'.(*>|v|^R19l894'^. 



Of WASH^^ 



/ 



NEW YORK : ^-^-^^Ij::^ ^ ^ ^ 

E. B. TREAT, 5 COOPER UNION, / ^ ^/ 
London : H. K. Lewis, 136 Grower Street. 

1894:. 

Price, $2.75. 



f^:\ty 






Copyright, 

By E. B. TREAT, N. Y. 

1888-1894:. 



PREFACE, 



The affections treated of in the following pages have 
ever shown a decided predilection for the neurotic 
portion of our population. For the great towns of the 
Atlantic seaboard, headaches and neuralgias exhibit a 
special preference. To the nervous exhaustion and 
strain incident to the irregular mode of life and com- 
petition of the great cities are due. in no small degree, 
these head -pains so often the precursors of impending 
nervous bankruptcy. The same causes, in conjunction 
with one of the most trying climates to be found in 
the whole world, serve also to give rise to a thousand 
aches and pains, the most excruciating of which are 
those neuralgias of the face that not infrequently drive 
the victim to suicide or the madhouse. 

For several years past I have devoted much time to 
the careful study of these prolific sources of human 
misery. I have not done this in a spirit of mere path- 
ological analysis; but I can truly say that my endeav- 
ors have been of a practical kind, every thought being 
directed to the rehef and cm-e of these distressing 
affections. 

As insomnia is one of the most constant and dis- 



8 PREFACE. 

tressing accompaniments of pain, I have added a chap- 
ter on sleep and its derangements, which I trust will 
lend completeness to the general argument. 

When to personal experience I add the fact, that 
many of the principles herein formulated have already- 
been extensively promulgated and kindly received by 
my professional brethren on both sides of the Atlan- 
tic, I may perhaps claim extenuation for confidence 
placed in my own undertakings. 

PEEFACE TO THE SECOND EDITION. 



The kind reception which the first edition of this 
work received at the hands of the profession has been 
an agreeable surprise to the author. 

As regards the second edition, I may state that the 
value of the work has been materially enhanced by 
the addition of an appendix on the relation of eye 
strain to headache, contributed by my distinguished 
friend, Dr. David Webster, of New York. 

Dr. Webster's reputation as an accomplished oph- 
thalmologist is a sufficient guarantee of the soundness 
of his opinions. 

J. L. Corning. 

New York, September 1st, 1889. 

PEEFACE TO THE THIED EDITION. 



To this, the third edition, I have added a chapter 
on the "Localization of the Action of Eemedies upon 
the Brain," which I trust may prove suggestive as 
well as useful. 

J. L. Corning. 

New York, January 1st, 1894. 



CONTENTS, 



PART I.— HEADACHE. 
Pains which owe their Origin to Intra-Cranial Causes. 

PAGE. 

I. General Considerations on the Mechanism of Head- 
Pains ; Classification of Head-Pains 15 

II. Anaemic Headache 22 , 

III. Hyperagmic or Congestive Headache 26 

lY. Nervous or Cerebral Headache 38 

(a) Cerebro-Hypertemic Headache, 

(b) Cerebro- Anaemic Headache. 

V. Toxic Headache 44 

VI. Sympathetic Headache ; Bilious Headaclie 47 

VII. Organic Headache, or that which is dependent upon 
profound Changes in the Constitution of the Brain or 

its Membranes 52 

VIII. Cases Illustrative of Various Phases of Headache ... 56 

PART II.— NEURALGIA. 
ains which owe their Origin to Extra-Cranial Causes. 

IX. General Considerations 63 

X. Classification of Neuralgia — (1) Trigeminal (Facial) 

Neuralgia 66 

XI. Trigeminal Neuralgia continued. Modification in the 
Symptoms of Facial Neuralgia, consequent upon the 
Restriction of the Pain to one or more Branches of 
the Nerve ; (2) Cervico-Occipital Neuralgia ; (3) Cer- 

vico-Brachial Neuralgia 69 

Xn. Other Varieties of Neuralgia 73 

(4) Crural Neuralgia. 

(5) Lumbar Neuralgia. 

(6) Lumbo-Abdominal Neuralgia. 

(7) Dorso-Intercostal Neuralgia. 

(8) Sciatic Neuralgia. 



10 CONTENTS. 

, (9) Plantar Neuralgia. 

(10) Coccygodynia. 

(11) Mastodj'nia. 

(12) Muscular Neuralgia. p^oe 

XIII. Causation 79 

XIV. Diagnosis 83 

XV. Pathology 84 

XVI. Prognosis 86 

XVII. Treatment in General 88 

XVIII, Local Medication of Nerves, Authors Method 93 

XIX. Local Medication of Nerves continued. The Prolonga- 
tion of the Local Action of the Remedy, Author s 
Method ; Cases Illustrative of various Phases of 
Neuralgia ; The Endermic Use of Remedies in Neu- 
ralgia 97 

PART III.— HISTORICAL. 

CONSIDERATIOX OF METHODS OF TREATMENT 
HERETOFORE PROPOSED. 

XX. Methods Involving the Use of Electricity 119 

XXI. Electric Methods continued. Simultaneous Applica- 
tion of Pressure and Galvanism 121 

XXII. Narcotics and Sedatives 125 

XXin. Other Remedies which have been Recommended ; 

Treatment by Freezing 132 

XXIV. Surgical Exped'ients 138 

XXV. Some Concluding Observations on Rheumatic, Osteal 

and Periosteal Head-Pains 140 

PART IV.— IRRITATIVE CONDITIONS OF THE SPINE. 

XXVI. Spinal Irritation 145 

XXVII. Spinal Irritation and other Painful Symptoms conse- 
quent upon Slight Local Injurj^ or General Shock. . 169 

PART v.— NORMAL AND MORBID SLEEP. 

XXVIII. Considerations on the Physiolog}' of Sleep 187 

XXIX. Idiopathic Insomnia 201 

XXX. Secondary Insomnia 206 

XXXI. Considerations on Dreams 209 

XXXIL The Difference between Dreams and Waking Thought. 215 

XXXm. Morbid Somnolence 219 

XXXIV. General Observations on the Treatment of Insomnia 222 

XXXV. Localization of the Action of Remedies upon tlie Brain . . 228 

Appendix : Eye Strain, a Cause of Headache 245 

Index 273 



PART I. 



HEADACHE 



PAINS WHICH OWE THEIR ORIGIN TO INTRA- 
CRANIAL CAUSES. 



CHAPTER I. 
INTEODUCTORY AND RETROSPECTIVE. 

GENERAL CONSIDERATIONS ON THE MECHANISM OF HEAD- 
PAINS.— CLASSIFICATION OF HEAD -PAINS. 

Under the designation of headache, I propose to 
consider a group of painful sensations located in the 
head, and usually accompanied by more or less sensory 
hypersesthesia, mental irritability and intellectual pros- 
tration. 

As the clinical significance of these head -pains 
differs more or less widely, it is not surprising that 
they should be attributable to the most varied causes. 
Thus experience has shown that some of these pain- 
ful sensations about the head may be due to extra- 
cranial causes, such as osteosis of the cranium and 
dura mater, syphilitic periostitis of the cranium, disease 
of the internal ear, neuralgic and rheumatic affections 
of the scalp, and tumors of various kinds. On the 
other hand, it is equally certain that an extensive 
category of headaches is directly attributable to intra- 
cranial causes. Under the latter conditions the mental 
disturbances are decidedly more marked than when 
the cause of the pain is located externally to the cranial 
vault, and we are therefore justified in speaking of 
these headaches as cerebral or brain-pains. 

Before proceeding to discuss the symptomatology of 
headaches, it will be well to consider the mechanism 



16 HEADACHE AND NEURALGIA. 

of their production, as classification and treatment are 
alike dependent upon some conception, however im- 
perfect, of the pathological features involved. 

Uf the purely extra -cranial pains little more need be 
said than that they are evidently one and all attribut- 
able to disturbances in the molecular conditions of jbhe 
sensory nerves involved. Whether the immediate 
source of such disturbances be an organic lesion (ex- 
ostosis, syphilitic periostitis), or whether it consists in 
some occult external (rheumatic, neuralgic) element, 
matters httle in so far as the final result is concerned. 

The elucidation of the mechanism of the intra- 
cranial or brain-pains is, however, a ma-tter of far 
greater difficulty. In considering this point. Dr. Sy- 
monds ' pertinently observes : ' ' Putting aside for the 
present any reference to the patient's feelings, what 
do we learn from anatomical considerations as to the 
probable source of pain within the craniuui when the 
patient is the subject of headache ? It does not appear 
to be in the nervous matter, whether vesicular or tub- 
ular, of the cerebral hemispheres, or of the cerebellum. 
No evidence of feeling has been obtained by vivisectors 
till they approach the sensory ganglia, the thalami 
optici and corpora quadrigemina. But these are the 
centres of sensations to all parts of the body as well 
as to the head. All analogy must further look to the 
nerves as the source of pain (though some writers are 
hardy enough to doubt the necessity of nervous mat- 
ter as instrumental in sensation). And what are the 
nerves ? Numerous as are the nerves which come out 
of the cranium, there are on a superficial view very 
few that go into it, A branch of the suboccipital ac- 
companies the vertebral artery, but a large majority 

' " Tlie Gulstonian Lectures on Headache," Medical Times and 
Gazette," 1858. 



INTRODUCTORY AND RETROSPECTIVE. 17 

of the other nerves, destined for intra- cranial purposes, 
are derived from the sympathetic. 

" These, then, are the nerves which are of chief inter- 
est to our present inquiry. Nerves of this class accom- 
pany blood-vessels, and when we observe the large 
amount of these vessels, the brain and its membranes 
being more liberally supplied with blood than any 
other organ (the quantity being computed as one- fifth 
of the blood of the whole body), we might, without 
searching further, feel convinced that there must be a 
corresponding supply of ganglionic nerves; but the 
minute examination of modern anatomists has tracked 
them in great abundance. ' ' 

Discussing the same point, Memeyer' observes 
that: "Headache, a very frequent symptom in all 
cerebral diseases, is very difficult to explaiu; we do 
not even know if it is of central origin (that is, if it 
originates in the parts of the brain where irritation 
causes symptoms of pain after the insensible greater 
hemispheres have been removed), or whether, as I 
think is more probable, it depends on initation of the 
filaments of the trigeminus going to the dura mater. 
The great sensitiveness to impressions on the senses 
depends on the increase of excitability, caused by tlie 
cerebral hyperaemia, or the hyperaesthesia of those 
portions of the brain through which peripheral irrita- 
tions are perceived. The patients do not exactly feel, 
see, and hear more sharply than ordinarily, but they 
are annoyed by irritations far weaker than such as 
usually annoy them. Light troubles them; a slight 
sound or an insignificant irritation of the nerves of 
touch excites disagreeable feelings. Morbid excitation 
(which must not be identified with increased excitabil- 

^ " Memeyer's Practical Medicine," Vol. II., p. 159, quoted by 
Dav. 



18 HEADACHE AND NEURALGIA. 

ity) of the same central parts causes the clazzhng he- 
fore the eye. seeing sparks, roaring and buzzing in the 
ears, the sensation of formication, or of undefined 
pain, which are not induced by peripheral irritation." 

And again, Erb,' referring to the subject, feels com- 
pelled to admit that: '^Physiology affords little aid 
in determining the sensory nerves in which the irrita- 
tion is seated. Experiments upon the sensibility of 
different structures in the interior of the skull have 
given contradictory results: for whilst Leyden, Hitzig 
and Ferrier have found the dura mater to be highly 
sensitive, Pagenstecher ascribes a very low degree of 
sensibility to it, and Bartholow " who experimented on 
the human subject, found it to be but shghtly sensi- 
tive to mechanical stimuli. The greater number of 
experiments seem to show that the pia mater is also 
not very sensitive, and the same may be said in regard 
to the greater part of the substance of the hemispheres. 
When Bartholow pushed his needles deep into the 
substance of the cerebral tissue, pain was only ex- 
perienced in the neck after they had been pushed in to 
about the depth of the great ganglia at the base of the 
brain." 

''We are unable, again, from physiological consid- 
erations to explain why headache should be experi- 
enced when the intra-cranial disease is situated in so 
many different parts of the brain or of its membranes; 
we must either admit that the tissues, which under 
ordinary circumstances are insensible or are only en- 
dowed with a low degree of sensibility, become sensi- 
tive under pathological conditions, and give rise to 

' " Beard's Archives of Electrology and Neurology," New York, 
1874, p. G8. 

' "Diseases of the Peripheral Cerebro-Spinal Nerves," article 
"Cephalalgia," " Ziemssen's Cyclopaedia," p. 138 et seq., 187G. 



INTRODUCTORY AND RETROSPECTIVE. 19 

pain; or we may imagine that in diseased states the 
influence of pressure and irritation spreads to consid- 
erahle distances, involving tissues that are sensitive. 
The dura mater may undoubtedly be included amongst 
such sensitive structures, since it receives sensory 
branches from the trigeminus and vagus; perhaps the 
nerves of the choroid plexus, which Benedict ' has re- 
cently described, are of a sensory nature, and may be 
answerable for the ' internal ' headache sometimes com- 
plained of. To what special locality, however, we 
should refer these ' nervous ' headaches, is still unde- 
cided, and we can only offer guesses at the truth." 

The most recent theory regarding the mode of pro- 
duction of pain along the course of nerves, as in neu- 
ralgia, is that promulgated by Prus.'' According to 
this writer there are filaments in the sheaths of nerve- 
trunks, the irritation of which gives rise to the painful 
points found in neuralgic affections. These filaments, 
the presence of which was made known by careful 
microscopical examination, have received the some- 
what ponderous appellation of nervi nervorum peri- 
phericoriim. What part these structures are destined 
to play in the pathology of the future, experience 
alone can show. 

As to the opioions entertahied by myself with regard 
to the precise location and mechanism of these painful 
intra-cranial sensations, I can only agree with Xie- 
meyer and Erb that the ground we tread upon is un- 
certain; and that, as far as deriving definite conclu- 
sions from anatomy and physiology is concerned, we 
are left somewhat in the dark. This much I will ven- 
ture to affirm, however, that inasmuch as psychical 

^ Virchow^s Arch, band 59 

' Archives Slaves de Biologic, IV., 2 Sept, 1887. See also Brain, 
Vol. X., p. 557. 



20 HEADACHE AND NEURALGIA. 

disturbances assuming the form of grief, worry and 
apprehension are of themselves quite capable of evok- 
ing severe intra- cranial pain, the latter is certainly in 
some manner due to cerebral agency. That such a 
connection must of necessity exist, is shown bv the 
fact that when the disturbing psychical element is re- 
moved the pain frequently ceases instantaneously. To 
be sure such facts do not adequately explain the oc- 
currence of the form of headache due to a variety of 
purely physical causes, but they are nevertheless 
eminently suggestive, since they are clearly instances 
of headaches evoked by forces operating solely by and 
through the brain. 

On a superficial view, it would appear, then, that 
we meet with overwhelming obstacles on the very 
threshold of our investigation into the origin of these 
pains within the skull. The problem is, however, 
from a clinical standpoint at least, not so discouraging 
as it would appear at first sight; for, owing to the fact 
that we are acquainted with a considerable number of 
the factors concerned in the evolution of these pains, 
we are able to apply such knowledge to the practical 
ends of treatment. Again, although for the same rea- 
son, it is impossible to arrange the numerous varieties 
of headache upon the basis of their respective and 
ultimate pathological terms, we are at least able to 
classify the prominent forms of intra-cranial pain in 
accordance with their more obvious pathogenesis. Fol- 
lowing this method, we may classify the various forms 
of headache as follows: 



(1.) Anaemic Headache. 

(2.) Hypersemic or Congestive Headache. 

^ Nos. 3 and 5 are commonly known as " Sick Headache.' 



INTRODUCTORY AND RETROSPECTIVE. 21 

(3.) Nervous or Cerebral Headache. 

(a) Cerebro-Hyperaemic Headache. 

(b) Cerebro- Anaemic Headache. 
(4.) Toxic Headache. 

(5.) Sympathetic Headache. BiHous Headache, &c. 
(6.) Headache dependent upon organic disease of 
the brain or its appendices. 

EXTRA -CRANIAL HEADACHE. 

(1.) Neuralgia, General Considerations om 

(a) Rheumatic Headache. 
(2.) Osteal and Periosteal Headacheo 



CHAPTER II, 

ANEMIC HEADACHE. 

The proximate cause of this form of head-pain is 
deficiency of blood Avithin the cranial cavity. It is an 
almost invariable attendant on general anaemia and 
chlorosis, and consequently young women of feeble 
constitution are particularly liable to its attacks. The 
affection is not, however, restricted to any particular 
form of w^eaknesS; but, on the contrary, it is a common 
attendant on all forms of debility. Uterine hemor- 
rhage, epistaxis, haemorrhoids, mal-nutrition, chronic 
diarrhoea and over exertion both mental and physical 
may produce it. Masturbation in both sexes may give 
rise to it; and excessive indulgence in strong tobacco 
may cause it. One of the most prolific predisposing 
causes of the affection is morbid sexualisnij as I have 
frequently observed both in married and single indivi- 
duals. 

Symptoms. — Sometimes those affected by this variety 
of headache complain of a sensation of tightness about 
the forehead, as though the head were encircled by a 
band. Sometimes again the pain is more restricted in 
character and manifests itself in clawing sensations, 
which are particularly well marked at the vertex. 
Whatever the location of the pain may be, it is 
almost invariably less pronounced when the subject 
is in the recumbent position than when the body is 
maintained in an erect attitude. Less pain is there- 
fore felt during the latter part of the night and early 



ANEMIC HEADACHE. 28 

morning than during the day. In the more exquisite 
cases the simple act of rising is sufficient to cause 
vertigo and even syncope; indeed symptoms of giddi- 
ness and weakness in the lower extremities are almost 
constant accompaniments of this form of headache. 

Sleep is also more or less affected, though during the 
day the subject is frequently beset by a morbid drow- 
siness which he endeavors to exorcise by the copious 
use of stimulants. The energy of the heart's action is 
reduced; and in very severe cases the venous murmur 
may be present in the neck as well as oedema of the 
ankles and of the legs. The latter condition is for- 
tunately rare. Palpitations, extreme fatigue upon the 
slightest exertion and attacks of sudden fainting are 
frequently met with. The surface of the body and 
particularly the face are cold to the touch, and the 
countenance has a peculiarly blanched and waxy ap- 
pearance. A morbid susceptibihty to sensory impres- 
sions, particularly of light and sound, is present in 
most cases. The sensitiveness to light is often so great 
that the subject insists upon remaining in a darkened 
room during the day, while an artificial light of any 
kind is absolutely unendurable. The susceptibility to 
acoustic impressions of all kinds may also be abnor- 
mally increased, so that such trivial occurrences as the 
squeaking of a door, the rumbling of a cart, or ordin- 
ary conversation are absolutely unendm^able. 

The peculiar flaccid state of the heart, which is so 
characteristic of this condition, has been graphically 
alluded to by Dupuytren as " relachement du coeur. " 

A symptom of considerable diagnostic importance 
is the feeble pulsation of the carotids — a phenomenon 
which is never absent in pronounced cases. Very 
slight pressure upon these arteries is sufficient, where 
the ana3mia is severe, to provoke an immediate attack 



24 HEADACHE AND NEURALGIA. 

of syncope. I first called attention to this symptom 
some time ago, and I have since had occasion to 
verify the assertions then made over and over again. 
The surface thermometer when properly applied 
over the vertex shows a considerable diminution in 
temperature as compared with the rest of the body. 
Again, persistent drooping of the eyelids is an almost 
constant symptom in this form of headache, and one 
of considerable diagnostic value^ from the fact that 
the phenomenon may be produced experimentally by 
the aiDpropriate apphcation of compression to the caro- 
tids, as I have frequently demonstrated.^ 

Treatment. — The temporary relief of this form of 
headache is a matter of no great difficulty, especially 
if the cerebral anaemia is due rather to vaso motor 
than to general causes. 

The inhalation of a few drops of the nitrate of amyl 
is often followed by immediate relief, but the latter is 
usually of only temporary duration, unless special 
means be adopted to perpetuate the good effects of the 
remedy. This object may be accomplished in a variety 
of ways: the inhalations of the nitrate may be repeated 
several times a day; the patient may be placed upon a 
sofa or bed, the foot of which is elevated by means of 
blocks of wood; alcohol may be given in frequent 
doses; the salts of iron and quinine may be adminis- 
tered, or opium may be given in small doses, a mode 
of treatment which has yielded good results in the 
hands of various practitioners in certain cases. 

Of all the remedies above enumerated pre-eminent 
importance must be assigned to alcohol; when taken 
in moderate quantities it increases the energy of the 
heart's action and at the same time causes dilatation 



* "Brain Rest," by J. Leonard Coi-ning, Gr. P. Putnam's Sons. 
Also the various papers and articles alluded to in this work, 



I _. 



ANEMIC HEADACHE. 25 

of the minute blood-vessels of the brain. It should 
never, however, be given in very lai^ge quantities, since 
when thus administered it causes depression of the 
nervous centres, besides exercising the most prejudicial 
effects upon the digestive and assimilative systems. 

McTjane Hamilton has found that the inhalation of 
nitrous oxide is of great benefit in anaemic headache. 
The ordinary apparatus used by dentists was employed 
in administering the gas. 

The importance of maintaining a horizontal position, 
especially during the early stages of the affection, can 
hardly be overestimated; and the benefits thence to be 
derived may be greatly enhanced by elevating the 
lower extremities by means of cushions, or preferably 
by raising the foot of the bed or lounge by means of 
blocks placed beneath the feet. 

After all has been said, however, with regard to re- 
medies, it must be admitted that the ultimate reliance 
of the physician consists in enhancing the powers of 
the apparatus of digestion and absorption. Cod-hver 
oil, rare beef -steaks and mutton-chops should occupy 
a prominent place in the dietary; while milk and eggs 
may be given ad libitum, where the digestive powers 
are not seriously impaired. 

As a matter of course, if the anaemia be due to the 
presence of some obviously morbid element^ the latter 
should be gotten rid of as soon as possible. If the di- 
gestive apparatus is impaired it should be put in good 
condition as soon as possible; if there is hemorrhage 
from the uterus or any other portion of the body it 
should be arrested, and in short from whatever source 
the debih fating influences emanate, they should be 
neutralized or removed as expeditiously as circum- 
stances will admit. 



CHAPTER III. 

HYPER^MIC OR CONGESTIVE HEADACHE. 

Syinptoincdologij. — In this form of head-pain the 
subject complains of a severe tensive pain, and at the 
same time experiences a sensation of fuUness, as 
though the cranium were too small for its contents. 
As a rule the painful sensations are not circumscribed 
in character, but are distributed throughout the entire 
extent of the cranium. The pain is constant, and is 
augmented by assuming the recumbent posture; conse- 
quently sleei3 is more or less profoundly affected. All 
forms of mental or physical exertion are followed by 
exacerbations of pain accompanied by more or less 
vertigo. The subject is extremely irritable and aroused 
to inordinate passion by the most trivial circumstances; 
he is pessimistic, depressed and lachrymose, and in- 
ch ned to find fault with all about him. Sensory dis- 
turbances are also more or less common, and may con- 
sist in functional exaltation or depression. 

Sometimes the action of the heart is inordinately in- 
creased in strength and considerably accelerated, so 
that the patient complains of throbbing in the tem- 
poral and carotid arteries, which in some cases is so 
violent as to be easily discovered with the naked eye. 

There is also a well-marked increase in temperature, 
particularly above the vertex, and the face is suffused 
to such a degree as to present a livid, coppery appear- 
ance. 

Causation. — The immediate cause of the above 
group of symptoms is an increase in the arterial blood- 



CONGESTIVE HEADACHE. 27 

tension, accompanied by more or less relaxation on the 
part of the cerebral cai)illaries. A somewhat similar 
series of phenomena may, however, be evoked by dis- 
tension of the intra-cranial veins consequent upon 
some form of obstruction to the flow of blood in the 
same (passive congestion). When the impediment is 
serious, coma may be induced. Yaso-motor insuffici- 
ency, especially that affecting the intra-cranial circula- 
tion, is a prolific cause of the congestive form of head- 
ache ; it may result from the most varied causes, and 
is especially prone to occur as the consequence of 
excessive sexualism and the protracted abuse of alco- 
holic stimulants. To enumerate all the pathological 
conditions which may give rise to this form of head- 
ache would, however, involve the recapitulation of a 
considerable segment of special and general pathology, 
and would, of course, be supererogatory in a work of 
this kind. 

Treatment. — Without doubt the most expeditious 
mode of affording relief in uncomplicated cases of con- 
gestive headache —those which are attributable to 
abnormal heart or vaso-motor conditions, or both — 
consists in the skillful application of compression to 
the common carotid arteries ' by means of appropriate 
instruments. Electro-compression ' also yields excel- 

^ " Prolonged Instrumental Compression of the Primitive Car- 
otid Artery as a Therapeutic Agent," by J. Leonard Corning, 
M.D., "New York Medical Record" for Feb. 18th, 1882. Also article 
in "Philadelphia Medical News," for June 17th, 1882 ; this arti- 
cle may also be found in the "American Journal of Neurology 
and Psychiatry," 1882. See also, " Carotid Compression," Anson 
D. F. Randolph & Co., New York, 1882, Ibid. "Brain Rest:" 
A Disquisition on the Curative Properties of Prolonged Sleep, 
by J. Leonard Corning; M.D., G. P. Putnam's Sons, New York, 
Second Edition, 188G. 

- For the original paper on the combined application of com- 



28 HEADACHE AND NEURALGIA. 

lent results, especiall}^ in those cases ^vhere the adipose 
covering of the neck is of such thickness as to render 
the application of strong pressure without implication 
of the jugular difficult or practically impossible. 

Of the two procedures electro-compression will on 
the whole be found most effective and universally ap- 
plicable. As some of my readers may not be familiar 
with the rules which I have elsewhere given for carry- 
ing out this mode of treatment, I will give the salient 
points involved. 

MODE OF EXECUTING ELECTRO-COMPRESSION. 

For applications of short duration, and these are the 
most uniformly useful in the treatment of congestive 
varieties of headache. 1 have found the following device 
convement : It consists in the first place of two curved 
metallic branches, resembling in shape an ordinary 
horse shoe. To each of the extremities of these 
branches is attached a small sponge electrode. These 
electrodes are insulated by means of hard rubber 
plates. To each of the electrodes is attached a con- 
ducting cord. These cords unite in one common stem, 
which being secured to the binding post of a galvanic 
battery renders the polarity of the two sponge elec- 
trodes the same. (Fig. 1.) 

It is possible by means of a screw provided with a 
detachable key to place the electrodes at an angle. 
The object of this device is to enable the operator to 
exercise pressure upon the carotids in an oblique direc- 
tion, so as to press them away from the jugular veins 

pression and electricity, see " Electrization of the Sympathetic 
and Pneumogastric Nerves, Avith Simultaneous Bilateral Compres- 
sion of the Carotids," by J. Leonard Corning, M.D., "The NeAv 
York Medical Journal " for February 23d, 1884 



ELECTRO-COMPRESSION. 



20 




Fig. 1.— Author's Electro-Compressor.— a a', insulated sponge electrodes in con- 
nection with the bifurcated conductiu,^ Avire 6; c, milled wheel, tli£ rotation which 
causes the screw d to act upon the armatures e e', thus enabling the operator to ex- 
pand or approximate the latter at will. 



30 



HEADACHE AND NEURALGIA. 



in the direction of the spinal column. By this means 
it is possible to reduce venous pressure to a minimum. 
Again, the branches themselves may be extended or 
approximated at will, an advantage obtained by the 
use of the Archimedean screw. An exceedingly fine 
adjustment is thus rendered possible. 

The method of employing the instrument just de- 




FiG. 2.— Showing Mode of Applying Electro-compression. A, differential calo- 
rimeter, connected with the thermo-electric piles d d, by means of the conducting: 
wires e e'. B, galvanic battery connected with the electro compressor C by means 
of the bifurcated conducting wire /. The electrode at the extremity of the other 
conducting wire /' is placed on the neck. 

cribed is exceedingly simple. The patient, if in bed, 
is placed in a horizontal and semi-dorsal position, with 
the head supported by a cushion beneath the neck, in 
such a manner as to allow the head to fall slightly 
backward, while the cervical vertebrae are protruded 
anteriorly (Fig. 2). The operator then takes his place 



ELECTRO-COMPRESSION. 3) 

by the bedside, his left side being turned toward the 
patient. Then, having with the index-finger and 
thumb ascertained by careful exploration the exact 
position of the carotids, he proceeds, after accurately 
adjusting the armatures, to apply the instrument in 
such wise that the electrodes will press the arteries 
away from the pneumogastric nerve and jugular vein 
in the direction of the spinal column. 

In applying the instrument it should be held in the 
right hand, the handle forming a perpendicular to 
the arteries. By pressing the left hand firmly against 
the posterior portion of the neck, the operator is 
enabled to execute any counter-pressure which may 
be required, and at the same time to contribute to the 
support of the head in the desired position. Compres- 
sion should, however, never be carried so far as to 
cause entire closure of the lumina of both arteries ; 
such a procedure may cause convulsions, as the anas- 
tomotic facilities at the circle of Wilhs are usually 
unequal to these unwonted circulatory exigencies. 
This contingency is, however, not liable to arise, as 
the degree of pulsation in the temporal arteries affords 
reliable information as to the extent of the circulatorv 
obstruction. 

When the instrument has been properly adjusted, 
an assistant applies the disengaged electrode (usually 
the positive) over the posterior aspect of the cervical 
vertebrae. 

All being in readiness, the strength of the battery is 
gradually increased. 

It is impossible to determine in advance how many 
cells may be required, as this will depend greatly 
upon the strength of the battery, the thickness of the 
cervical adipose tissue, and the degree of compression 
employed. The greater the amount of compression the 



32 HEADACHE AND NEURALGIA. 

less the strength of the current should be, and vice 
versa. 

Care should be exercised to avoid dizziness or syn- 
cope, and the strength of the current and degree of 
pres3U]^e should at all times be regulated with the ut- 
most nicety. Sudden variations in either of these 
factors are to be carefuU}^ avoided. By this mode of 
treatment we accomplish a threefold end: (1) Dimi- 
nution of the amomit and pressure of the cortical 
blood- stream; (2) Contraction of the cerebral capil- 
laries; and (3) Eeduction of the intensity of the 
heart's action (when currents of considerable strength 
are employed). 

I have frequently caused entire cessation of the con- 
gestive form of head-pain in the course of from five to 
eight minutes by the use of this method of treatment. 

Only secondary in importance to the above method 
of treatment is the application of cold to the head. 
This may be done by means of the ice-bags in general 
use, or better still by the employment of the apparatus 
recommended by Mr. Joseph Leiter, Dr. Knowsley 
Thornton and others. This appliance consists in a 
series of india-rubber spirals, which are wound around 
the head in the form of a cap. By passing a stream of 
cold water through these spirals it is possible to main- 
tain the water in them at an exceedingly low tempera- 
ture. This method of treatment has been extensively 
employed, I believe, by Mr. Spencer Wells of London, 
especially after the operation of ovariotomy. 

This ice- water cap may be employed with increased 
benefit in conjunction with hot water both to the feet 
and calves; the effects thus attahiable being striking. 

Hot baths to the entire body ranging in temperature 
from 103° to 110° may be prescribed with advantage, 
where other means of treatment are not accessible. 



BATHS. 



33 



Baths of this cliaracter a,ffect the central nervous 
system to a niucli greater extent, and in a shorter space 
of time than warm baths. The skin becomes rapidly 
congested ; respiration is increased and inspiration 
becomes deeper. As a rule these baths are followed 




Fig. 3.- Mode op Applying Ice-water Cap. (After Letter.) 

by profuse perspiration, and their derivative action 
upon the engorged cerebral centres is not to be over- 
estimated. 

The hot-air or Turkish bath has a wide application 
in the treatment of the congestive form of headache; 



34: HEADACHE AND NEURALGIA. 

and I have no hesitancy in recommending its employ- 
ment in this connection, though fully aware that a 
prejudice exists against the use of hot haths in brain 
affections. The sojourn of the patient in the hot-room 
should not, however, be of too long duration ; twenty 
or thirty minutes are quite enougli. When possible, 
the subsequent application of the douche should be in 
the form of the hot water stream, as recommended by 
certain French physicians, in order to redden the skin, 
especially about the back and lower limbs. As soon 
as this operation is completed the patient should be 
put to bed and wrapped in warm blankets. 

A most excellent expedient, in severe cases, is the 
application of a leech at each side of the septum narium, 
about half an inch above the nares. This may easily 
be accomplished by the aid of a curved leech glass. 
The hemorrhage which follows is sometimes profuse, 
but may be arrested by the application of a tampon of 
styptic cotton on each side of the septum. In order 
to increase the bleeding, it is only necessary to hold 
the head over a bowl of hot water. 

Should the liemorrhage from the mucous membrane 
prove obstinate, the application of a soHd point of 
nitrate of silver over the bite may be resorted to. It 
is hardly necessary to add tliat, in the application 
of leeches to the septum, care should be taken to 
prevent the passage of the animals into the nasal 
cavity. This may be accomplished by previously 
plugging the nostrils with cotton wool. In order to 
avoid the employment of leeches, I have had con- 
structed an apparatus, by means of which artificial 
epistaxis may be produced in a satisfactory manner, 
and without the slightest possibility of accident. 

It consists, in the first place, of the jar (e), which is 
connected with the air pump ih), by means of which 



ARTIFICIAL EPISTAXIS. 



35 



it is possible to cause a vacuum in the vessel (e). The 
gauge (/) registers the degree of approach to a vacuum. 
An india-rubber tube connects the jar with the small 
bottle (c), which is provided with a scale. A bifur- 
cated tube (h) connects the bottle with the two small 
cupping bowls (a d) ; the latter are sufficiently minute 
to admit of their introduction into each nostril respec- 
tively. As they are provided with india-rubber gar- 
nitures, it is possible to adapt them accurately to the 
sides of the septum. 




~^^^^^=^3!^p.^* 



Fig. 4.— Author's Apparatus for Artificial Epistaxis. 



The mode of employment is simple enough. The 
cupping bowls having been introduced, a small 
scalpel is inserted in turn beneath the edge of each, 
by means of which the mucous membrane of the 
septum is slightly scarified. The cupping bowls 
are then connected with the vacuum jar and with 
the bottle by opening the appropriate stop -cocks. 
These valves (^, ^, i, i) require no explanation, as their 
function is self-evident from the situation which they 
occupy. Short segments of glass tubing, inserted in 



36 HEADACHE AND NEURALGIA. 

the india-rubber pipes below the cupping bowls, enable 
the operator to observe whether the blood is flowing 
properly, or whether further scarification is necessary. 
As the blood flows into the graduated bottle already 
described, it is possible to determine with accuracy 
the amount removed. 

Blisters to the nape of the neck and sinapisms to the 
calves of the legs have been highly praised by some as 
adjuncts to other modes of treatment; while the scari- 
fication of the nape of the neck has also found advo- 
cates. 

The apphcation of the constant galvanic current to 
the head is a useful expedient in some cases, but too 
much reliance should not be placed upon it. 

On the other hand, dry- cupping when extensively 
practised is sometimes attended with happy results, es- 
pecially in the milder forms of congestion. A very good 
method for carrying out this form of treatment is to 
smear the posterior portion of the neck and the back 
throughout its entire extent with spermacetti ointment: 
the exhaust glass (which should be large) is then re- 
peatedly applied and voided by means of the air pump. 
This procedure is repeated until the entire back be- 
comes livid. It is evident that such a degree of super- 
ficial congestion must exercise no little derivative 
action upon the deeply seated tissues; and indeed the 
results obtained in cerebral and other forms of conges- 
tion are sometimes all that could be desired. Where 
the engorgement is very considerable, however, it is 
usually necessary to resort to some one of the more 
powerful remedies already referred to. Venesection, 
to which resort was had by the older physicians in 
congestion and other forms of headaclie, can only meet 
with unqualified condemnation by the modern neuro 
pathologist as at once a supererogatory and even dan- 



ELECTRO -COMPRESSION. 37 

gerous procedure. Local depletion by epistaxis— the 
most direct mode of affecting the cerebral circulation by 
blood-letting, — or compression of the carotids by means 
of appropriately constructed instruments, are certainly 
far more direct in their effects than general depletion, 
and at the same time quite devoid of danger or dis- 
agreeable consequences of any kind. 



CHAPTER IV. 

NERVOUS OR CEREBRAL HEADACHE. 

Under this designation I propose to consider that 
variety of headache which, in its typical form, is char- 
acterized by the absence of all circulatory derange- 
ments and neuralgic symptoms. The most logical 
supposition relative to the pathology of this form of 
headache is that which ascribes the painful phenomena 
to certain subtle morbid changes originating in the 
substance of the nervous centres themselves. To be 
sure, we have no further proof of the truth of this hy- 
pothesis than that afforded by the fact, that this 
variety of headache may be readily evoked by pro- 
found emotional disturbances — factors which appeal 
directly to the psychical centres — in the absence of all 
purely physical causes, such as neuralgia or derange- 
ments of the intra-cranial circulation. Neither this 
nor any other theory relative to the nature of the affec- 
tion can, however, be accepted as in any sense final. 

Unlike the anaemic and hypersemic varieties of head- 
ache, the form of the affection which we are consider- 
ing is not readily amenable to experimental inves- 
tigation, and hence, as already intimated, we are 
reduced to the necessity of forming our conclusions 
from data which, to say the least, are insufficient. 
Pending more exact knowledge, however, the theory 
which ascribes the phenomena of the affection to 
some subtle disturbance in the cerebral substance may 
be accepted; and it may also be added that this hypo- 



NERVOUS HEADACHE. 39 

tliesis will be found to lead to a thoroughly enlight- 
ened and effective practice. 

Symptoms. — In many persons the onset of the head- 
ache is marked by the occurrence of digestive derange- 
ments in the form of eructations, flatulency, or consti- 
pation. There is always more or less malaise and 
mental irritability in the beginning, and the latter 
symptoms usually become greatly exaggerated in the 
course of a few hours. 

The pain begins in some persons with a certain 
amount of visual disturbance; the sight becomes 
clouded, and at the same time an acute pain is felt in 
tjie corresponding temple. With these symptoms the 
|)atient usually experiences more or less nausea, con- 
fusion of ideas and vertigo ; while, at the same time, 
his thoughts become concentrated on his real or antici- 
pated misfortunes, with the result of greatly augment- 
ing the intensity of the head-pains. Sometimes the 
pain is felt in the vertex, forehead or occiput ; but in 
a considerable percentage of cases, it becomes located 
in one temple, in one -half of the head, or in one eye ; 
so that the supposition may be formed that the nerves 
of the head are implicated, as in neuralgia. 

There is also more or less sensitiveness to sensory 
impressions of all kinds ; the patient shuns the light 
and stops her ears with pledgets of cotton, or with her 
fingers, in order to keep out the din of the house and 
street. 

Sometimes the subject complains of feeling as 
though her eye were being forced out of the socket, or 
as though the side of her nose were being burned with 
a hot iron. 

I have already mentioned the cerebro-hyperaemic and 
cerebro-anaemic varieties of headache, in the table of 
classification at the head of this article. It would be 



4:0 HEADACHE AND NEURALGIA. 

an easy matter to discourse at length upon those mod- 
ifications of the nervous headache, but to do so would 
be somewhat supererogatory, since, in their fundamen- 
tal characteristics, they are closely allied to the latter 
affection. The only point of difference consists in the 
presence of certain vaso-motor disorders of the cerebral 
blood-vessels, which find their chief clinical expression 
in either pallor or flushing of the countenance and in 
diminution or increase in the strength of the carotid 
pulse. These circulatory phenomena are, however, 
strictly speaking, purely secondary to the primary 
morbid changes in the cerebral substance. It is 
well to bear this fact in mind, since, if the efforts of 
the physician be directed solely toward the modifi- 
cation of these vascular changes, he will inevitably 
meet with disappointing results. On the other hand, 
if appropriate efforts be made to remove the primary 
condition of irritability, resident in the cerebral sub- 
stance itself, good and even brilliant results may often 
be obtained in a comparatively short period of time. 

Causation. — The most potent predisposing element 
is undoubtedly found in the neurotic and impression- 
able constitutions of the patients, or their ancestry. 
Debilitating diseases, spermatorrhoea, leucorrhoea, 
mental disorders, and profound digestive disturbances 
may also predispose to the occurrence of the nervous 
or cerebral form of headache. 

Among the exciting causes, worry, disappointment, 
pecuniary losses, and in short the whole category of 
depressing emotions occupy the most prominent posi- 
tion. Only secondary to these in importance is ex- 
haustion of the nervous centres, particularly those of 
the brain. 

Treatment. — The point of paramount importance is 
to calm the irritable nervous centres. This is best ac- 



NERVOUS HEADACHE. 41 

complished by the administration of remedies which- 
exert a soothing influence upon the cerebral paren- 
chyma, and at the same time tend to promote sleep. 
To this end, I usually administer the bromides in ten, 
twenty or even thirty-grain doses, where the stomach 
is sufficiently tolerant, and follow these remedies with 
a hypodermic injection of from one-eighth to one-sixth 
of a grain of morphia. At the same time, the patient 
being secluded in a dark room, ice is applied to the 
head— a procedure often followed by excellent results, 
especially if there be some tendency to cerebral con- 
gestion. 

On the other hand, if the face is bloodless and the 
conjunctivae are pale, the hot- water bag is indicated, 
and should be resorted to at once. The question as 
to whether the elastic band ' should be applied above 
the superciliary arches, will depend greatly upon 
whether there are any concomitant neuralgic symp- 
toms or not. Where these are present, the pressure 
caused by the band is usually not well borne, and 
consequently this otherwise useful adjunct to treat- 
ment is contra -indicated. 

If sleep is not readily produced by the remedies 
above indicated within a reasonable length of time, 
hyoscyamus may be prescribed. I usually give it in 
the form of tincture in drachm doses, either alone or 
combined with the bromides. Chloral has been recom- 
mended in nervous headache by some writers, but is 
not to be compared with the 'hypodermic injection of 
morphia. 

If the subject, as not infrequently happens, is averse 

' The object of the elastic head-band is to compress the vessels 
of the scalp, thereby materially reducing the diffusive influence 
of the extra-cranial blood stream, and rendering the effects of 
cold or hot applications upon the braiu much more hitense, 



42 HEADACHE AND NEURALGIA. 

to its subcutaneous exhibition, it may be gi\^en in the 
form of suppositories, but the effects thus obtainable 
are not always as striking as those witnessed when 
the remedy is injected beneath the skin. 

If there is pain over the temple or in the eye. and if 
the subject complain of "soreness in the teeth" and 
neuralgic pains in the face, it is well to make the in- 
jection in the neighborhood of the painful district, 
though this is considered unnecessary by some authors. 

It is sometmies stated that, while morphia is very 
efficacious at the beginning of the attack, it is of less 
value after the headache has continued for some time. 
My own experience does not corroborate this state- 
ment ; and I have not the slightest hesitancy in stating 
that, previous to the introduction into practice of 
antipyren, this remedy was the one upon v/hich I 
based a goodly portion of my hopes whether the pa- 
tient was seen after the pains have become estab- 
lished, or at their very inception. 

The aim of the physician, when brought face to face 
with a severe case of nervous headache, should be to 
afford relief, and that as speedily as possible : indeed 
it is almost impossible to overestimate the suffering 
incident to one of these attacks : and the confidence 
and gratitude inspired by prompt and succesful treat- 
ment are a source of lasting satisfaction to physician 
and patient alike On the other hand, want of success 
brings mortification, if not permanent loss of profes- 
sional prestige. If possible, it is well to see the patient 
towards evening, when the soporific tendency conse- 
quent upon habit is greatest. 

As soon as a diagnosis has been made, antipyren 
may be exhibited in doses of fifteen grains every 
twenty minutes during the first two hours. The 
bromides may then be given — preferably in a dose 



NERVOUS HEADACHE^. i^ 

of from twenty to thirty grains in conjunction 
with one drachm of the tincture of hyoscyanms. 
Should there still he persistent pain the eighth of 
a grain of morphia may he injected heneath the 
skin. Sympathizing friends should then be sent 
away, and the patient allowed to remain quiet in 
a perfectly dark room, while the medical attendant 
occupies a neighboring apartment, leaving the door 
ajar. If in due course of time the patient fall asleep, 
the attendant may depart, resting assured that on 
the following morning there will be improvement, if 
not absolute cure. Should sleep, however, remain 
absent after these first endeavors, there should be no 
hesitancy on the part of the physician in resorting to 
a further hypodermic injection of morphia, even though 
there be nausea and a tendenc}^ to vomit. Usually, 
though not always, the nausea may be controlled by 
giving half a grain of cocaine in a teaspoonf ul of watei- 
just previous 1 3 making the injection. I make it an 
mvariable rule never to leave the patient until sleep 
has been produced, as the therapeutic effects of eight 
or nine hours of unconsciousness are simply marv^ellous 
in these cases. Sleep, indeed, is the grand objective 
point of all treatment, in so far as the realization of 
permanent cure is concerned. Its skiUful induction in 
the cases which we are considering will often procure 
the physician lasting gratitude, with the advantages 
which naturally foUow. 



CHAPTER V. 

TOXIC HEADACHE. 

This form of headache is caused by some chemical 
change in the constitution of the blood, due either to 
poisonous substances introduced into the system from 
without, or evolved in the economy itself through the 
agency of some organic or functional derangement. 

The best instance of the first named condition is the 
headache due to alcoholic poisoning ; while the head- 
pains of Bright 's Disease and of fevers, are examples 
of the effects produced by septic influences arising 
from morbid processes within the organism itself. 

Symjjtoms. —The nature of the pains arising from 
toxsemic causes is variable in character. Sometimes 
the subject complains of a heavy, dull sensation in the 
head, which may or may not be accompanied by ver- 
tigo. Again, the pain is sharp, and is described as 
splitting or boring. This is the form of headache 
described by Fournier; ' it is frequently met with 
among other phenomena of secondary syphilis. 

According to the extent of the intoxication, the fac- 
ulties of the mind are more or less affected. There 
may be delirium as in violent febrile disturbances, or 
the only symptoms noticed are heaviness and slight 
mental confusion, as in the headache resulting from 
inhalation of carbonic acid gas. 

The latter form of headache is frequently met with 
among the school children of Germany, who, owing to 

* Fournier, " Legons sur la Syphilis, ■' Paris, 1873. 



Toxic ilfiADACHEJ. 45 

the defective ventilation of educational institutions, 
are compelled to breathe the same air over and over 
again. The prejudicial effects of such bad hygienic 
arrangements are not alone confined to the central 
nervous system, but are visible in other departments 
of the economy as well. Facial pallor, baggy muscles 
and permanent interference with the processes of 
growth and physical evolution are some of the penal- 
ties which are the inevitable result of flagrant dis- 
regard of the most ordinary sanitary laws. 

Among workers in brass and chemical manufac- 
tories a dull, heavy, persistent form of headache is fre- 
quently encountered, which is evidently the result of 
the noxious fumes such persons are compelled to inhale 
during a considerable portion of each day. 

Chronic lead poisoning frequently gives rise to head- 
ache of an aggravated and persistent type, and the 
same may be said of the toxic effects of a large num- 
ber of other substances, such as the noxious gases 
already alluded to, narcotics, and alcoholic stimulants. 

Uraemic intoxication is another and common source 
of headache. The secretory power of the kidneys be- 
comes impaired by reason of the destructive inflamma- 
tory changes incident to chronic diseases ; the excre- 
mentitious matters of the blood accumulate, and their 
presence is manifested by disturbances of the central 
nervous system — headache, drowsiness and coma. 
Every physician is acquainted with cases of this kind, 
and nothing more need be said regarding them, except 
that the headache in question is often an early warn- 
ing of renal trouble. 

Treatment, — When the headache is the result of the 
introduction of some noxious substance into the sys- 
tem, every effort should be made to eliminate it from 
the economy. The bowels should be opened ; diuretics 



46 HEADACHE AND NEURALGIA. 

should be given, and the secretions of the skin stimu- 
lated by appropriate diaphoretics. 

Buckthorn (rhamnus), o, purgative which I have 
fouiid most useful in asylum practice, is particularly 
applicable in this variety of headache ; it may be given 
in the form of the fluid extract, in doses of from one 
to two drachms. The fluid extract of aloes may also 
be given, but I prefer the buckthorn. Whatever the 
purgative employed it should be fluid in form, in order 
to obtain as speedy action as possible. 

Pilocarpin is useful, but I prefer the Turkish or 
Eussian bath. 

If the headache be the result of some form of con- 
stitutional disease, such as syphilis, it is evident tha,t 
the efforts of the physician should be directed to the 
primary affection. The same may be said of the head- 
aches of fevers and kidney affections. It is clear, 
from these cursory remarks, that the proper treatment 
of this form of headache requires no little insight and 
tact on the part of the medical attendant. To attempt 
to deal with such cases by the aid of any stereotyped 
procedure would avail little; and to lay down any such 
arbitrary laws on the subject, would be but a lament- 
able confession of pedantry. 



CHAPTER VI. 

SYMPATHETIC HEADACHE, BILIOUS HEADACHE. 

This is a very common though obscure form of head- 
ache, being dependent upon eccentric sources of irrita- 
tion. Any disease of the peripheral organs may cause 
it. Ovarian or uterine affections, hemorrhoids or 
decayed teeth may give rise to it ; but its most prohfic 
cause is undoubtedly found in the manifold digestive 
disturbances, to which those of feeble constitution are 
hable. It would be a mistake, however, to imagine 
that the sole explanation of its origin is to be sought 
in peripheral disturbances alone, though these un- 
doubtedly constitute the exciting factor. A certain 
impressionability of the sensorium, such, for example, 
as that exhibited by neurotic young women, is essen- 
tial, in order that the irritation proceeding from a dis- 
tance shall culminate in the production of the painful 
sensations. 

All kinds of hypotheses have been advanced in ex- 
planation of these curious head -pains ; the most uni- 
versally accepted is that which assumes that the peri- 
pheral irritation becomes manifest in the brain through 
the agency of the pneumogastrics and sympathetic 
system of nerves. Quite an array of clhiical facts 
might be advanced in support of this theory ; but to 
maintain its integrity by the aid of experimental physi- 
ology is, in the present state of knowledge, not so easy 
a matter. Still, some theory is better than none at 
all, and pending further researches, the opinions cur- 



4$ HEADACHE AND NEURALGIA. 

rently advocated may be accepted. Nor need this 
course cause apprehension, since the theory itself is a 
good guide, as far as actual practice is concerned, and 
can only lead to enlightened treatment. Of the latter 
point I shall take occasion to speak presently. 

As to the Symptoms themselves, very little particu^ 
larization is necessary. Sometimes the pain is local 
in character and may manifest itself in a sensation of 
fullness or constriction about the forehead, or it may 
DO of a rasping, clawing nature, confining itself to one 
lateral half of the head or to the region of the vertex. 

As a rule, the painful sensations are aggravated by 
stimulants ; but this is owing, in part at least, to the 
digestive disturbances which so frequently constitute 
the exciting cause of the affection. That form of 
headache characterized by the presence of a yellow 
skin, by the accumulation of bile in the duodenum, 
and by more or less imperfect digestion, has received 
the designation of ''bilious headache." There is 
every reason, however, to regard this variety of head- 
pain as of purely sympathetic origin, since the head- 
ache comes on after the digestive disturbances have 
become established, and disappears as soon as they 
have been removed. It is a matter of common ex- 
perience, moreover, that the '^sick" headache which 
supervenes upon minor gastric disorders is frequently 
relieved immediately by vomiting. 

True bilious headache is more common among men 
than among women, on account of the excesses of the 
table committed by the former. 

The pain may begin after any meal, but is more 
common after a hearty evening dinner than after lunch 
or breakfast. Sometimes, however, the headache be- 
gins in the morning as the result of a previous noctur- 
nal debauch, and renders the subject entirely unfit for 



SYMPATltEtIC AND BlLiOtrS HEADACHE. 49 

the duties of the day. The head may be hot or cold, 
but whatever the vascular conditions they are sec- 
ondary to the cerebral irritability which is the factor 
of prime importance. If vomiting takes place spon- 
taneously or by the aid of emetics, the relief experi- 
enced is often magical. When, however, the gastric 
and cerebral disturbances have persisted for a con- 
siderable length of time, the consequent irritability and 
exhaustion of the nervous centres is so great that the 
only chance of relief is more or less prolonged un- 
consciousness. Under these circumstances, sleep is 
certainly the remedy par excellence ; and to procure 
it, resort should be had to hypodermic medication 
alone, as the introduction of remedies into the in. 
flamed stomach is usually followed by vomiting, or at 
least great discomfort. 

Treatment. — The control of a single attack is, as we 
have seen, a matter of no great difficulty. To finally 
vanquish and definitely suppress the exciting cause 
of these paroxysms is, however, a task of greater 
magnitude. It involves in many cases nothing less 
than the removal of dyspeptic and other gastric dini- 
culties of long standing, and the tranquilization of a 
morbidly irritable nervous system. The first portion 
of the problem requires for its solution the manifold 
resources of general medicine. As to the suppression of 
morbid irritability of the nervous centres, all that has 
been said on the subject in the paragraph oji cerebral 
or '^ nervous " headache applies here with equal force. 
I will only add that the preparations of coca often 
prove exceedingly useful in treating this form of head- 
ache. This is partly due to the anaesthetic effect of 
the drug upon the irritable gastric mucous membrane ; 
and in part to the tranquillizing influence exercised by 
the coca upon the hiizher cerebral centres. 
i 



50 HEADACHE AND NEURALGIA. 

As all practitioners are aware, one of the most disa- 
greeable features connected with the treatment of this 
form of headache consists in the intolerance of the 
stoQiach to remedies. Until the introduction of the 
coca preparations into practice, I w^as frequently at no 
little loss as to the pursuit of a consistent plan of med- 
ication in such cases, owing to this same intolerant 
condition of the stomach. I soon ascertained, however, 
that by adding a certain quantity of the fluid extract 
of coca to the remedy that I was anxious to prescribe, 
the latter was borne wdth much less inconvenience. 
The good effects thus attained were greatly enhanced 
by the addition of half a grain of cocaine or more. 
This was particularly exemplified in those cases where 
I had occasion to prescribe considerable quantities of 
the bromides A pill compound of : Ees. Podophylli 
gr. i, Extr. Col. comp. pulv. gr. 1, Extr. Hyoscyami 
gr. i, Hydrarg. Chlor. mit. gr. 1, is an excellent cath- 
artic where brisk action on the liver is desired. The 
addition of a small quantity of the extr. of belladonna 
is advisable where the tendency to griping is pro- 
nounced. 

The following formula, recommended by Day, some- 
times renders good service where there is a tendency 
to flatulence and acidity : 



Sodae Bicarb. 




Bismuth Subcarb. 




Pulv. Acaciae, aa. 


3j. 


Spt. Amm. Arom., 


3ij. 


Sqr. Zingib., 


3 iij. 


Aquae purae, ad. 


1 viii. 



Two tablespoonfuls three times a day half an hour 
before eating. Here also the efficacy of tlie prescrip- 
tion is greatly enhanced when its administration h 



SYMPATHETIC AND BILIOUS HEADACHE. 51 

preceded by giving cocaine hydro-chlorate, half a grain 
in a teaspoonful of water. I have tested this point 
many times, often in exceedingly intractable cases. 

Bismuth in doses of from fifteen to twenty grains 
before meals may be given where there is evidence of 
intestinal irritability. 

Sometimes two or tliree drops of the tincture of nux 
vomica given every half hour for three or four hours 
renders good service. 

An excellent expedient is that of Dr. A. A. Smith,' 
who gives half a drachm of saccharated pepsin in a 
wineglassful of sherry three times a day at meal times. 
A drop or two of the tincture of aconite, given in a 
small quantity of water and repeated at intervals, some- 
times proves efficacious where the pulse is small and 
rapid. 

Where the extremities are cold tlie application of 
hot-sand bags, which have previously been covered 
with flamael, proves beneficial by equalizing the cir- 
culation and promoting the general comfort of the pa- 
tient. Quinine may also be given when there is a 
suspicion of malaria, or when there is pronounced 
facial pallor and weak carotid pulse; but should there 
be the slightest suspicion of cerebral congestion it 
should be withheld. 

' A lecture delivered at the Bellevue Hospital Medical College. 
"The Medical Record," September 15th, 1876. 



CHAPTER VII. 

ORGANIC HEADACHE. OR THAT WHICH IS DEPENDENT 
UPON PROFOUND CHANGES IN THE CONSTITUTION OP 
THE BRAIN OR ITS MEMBRANES. 

The consideration of this variety of head-pctin does 
not strictly speaking belong in a work of this charac- 
ter. For the sake of differential diagnosis, however, 
a word or two respecting its more important charac- 
teristics will be found of service. 

Headaches due to organic disease of the brain are 
usually more or less continuous in character and are 
referred to a circumscribed portion of the cranium. 
There may or may not be accomjDanying disturbances 
of sensation and motion assuming the form of local 
spasms, paresis or impairaient of vision. 

Sometimes cases are encountered in which progres- 
sive loss of muscular power, vertigo, visual impair- 
ment and derangement of the faculty of recollection 
are the prominent symptoms. If headache, accom 
panied by epileptic phenomena, disturbances of speech 
and facial paralysis, takes place at the period of ado- 
lesence, there is strong presumptive evidence that we 
have to do with organic disease, more especially if a 
history of previous syphilis is forthcoming. 

The probability that a correct diagnosis has been 
made is considerably enhanced if there is vomiting 
and inability to retain food on the stomach, in the 
absence of obvious gastric disturbance. 



ORGANIC HEADACHE. 53 

Organic disease is by no means as frequent a cause 
of headache as miglit be imagined from the percent- 
age of gross cerebral lesions. Nor is the diagnosis of 
this form of headache always an easy matter Some- 
times the headache resulting from organic changes 
may be circumscribed in character and located by the 
patient with great precision ; whereas a subsequent 
post-mortem examination may prove such localization 
to be entirely subjective, the lesion being found in an 
entirely different portion of the brain. Again, there 
may be more or less profound organic changes without 
headache ; or there may be intense local pains, more 
or less persistent in character, and which are wholly 
due to some circulatory instability. 

In the face of such facts, it is evident, that only 
by the exercise of the utmost caution is the liability 
of error to be reduced to a mininam. 

Causes. — The lesions which are most liable to give 
rise to this form of headache are : arterial disease, sy- 
philitic and other varieties of tumor, tuberculosis, 
cerebral softening, hydatids and ossified formations 
within the cranial vault and meningitis. 

Treatment. —The treatment of headache due to or- 
ganic lesions of the intra-cranial structures is in the 
highest degree unsatisfactory, as far as the prospect 
of ultimate recovery is concerned. This at least is 
true as regards non-syphilitic lesions. Where there 
is reason to believe that the disturbances are due to 
the presence of syphilis, the iodide of potassium should 
be given in large doses two or three times a day, and 
the treatment persisted in until improvement becomes 
evident. Sometimes there is no apparent benefit in 
the beginning ; but this should not deter the practi- 
tioner from persevering in the only course which offers 
the slightest hope of ultimate amelioration. 



54 HEADACHE AND NEURALGIA. 

And it must be confessed that great patience will be 
required, both on the part of the patient and physician, 
in order to withstand the lack of success which fre- 
quently attends the beginning of this heroic medica- 
tion. Sooner or later, however, if the lesion be really 
due to syphilis, improvement may occur, and the 
spectacle of the patient's improvement under such 
unpromising circumstances is an ample reward for all 
previous anxiety. 

The iodide of potassium has been recommended as 
efficacious in the treatment of non -syphilitic tumors, 
as well as in those traceable to specific influences. I 
cannot say that the bulk of clinical evidence accessible 
up to date goes far to confirm this opinion ; but in 
spite of this fact, it is evident that the iodide should 
always be given a fair trial in all doubtful cases. 

As to the treatment of the pains themselves, mor- 
phine is unquestionably the remedy upon which the 
greatest reliance is to be placed. There is one draw- 
back to its administration, however, the serious de- 
pression which it sometimes produces in neurotic, 
irritable subjects. This collateral disadvantage is 
best overcome by the administration of one of the coca 
preparations,— either the extract or Mariani's coca 
wine. I usually give the latter in wineglass doses 
as soon as there is the slightest tendency to depression. 
The amount of morphine required is of course exceed- 
ingly variable ; usually, however, one-sixth of a grain 
will be found to render good service, especially if fol- 
lowed by a drachm of the tincture of hyoscyamus, or 
ten grains of chloral. The latter remedy when given 
alone or in conjunction with the bromides usually fails 
to render substantial aid ; and I would therefore insist 
that opium in some form be invariably given previous 
to the exhibition of the cliloral preparations. Anti- 



ORGANIC HEADACHE. 55 

pyren has not helped me much in this class of cases, 
when given alone. In conjunction with small doses 
of morphine, however, I have seen good results follow 
its exhibition. 



CHAPTER VIII. 

CASES. 

Having in the preceding chapters discussed the prin- 
cipal phases of headache, it may perhaps prove of 
benefit to cite a few illustrative cases:— 

T. B., a merchant, native of St. Kitts, West Indies, 
was referred to me by the late Dr. Cornelius E. Ag- 
new, on account of severe headaches, accompanied by 
certain mental disturbances, such as temporary loss of 
memory and lassitude. 

Patient had already consulted several eminent Eng- 
lish authorities, among whoQi I believe was Sir Andrew 
Clarke. When I first saw this gentleman in November, 
1886, he exhibited the following symptoms : 

Periodic exacerbations of cerebral hypersemia, ac- 
companied by tensive pains and sensations of fullness 
in the head. Sometimes there is vertigo; at others 
the patient, though ordinarily of an even disposition, 
is irritable and aroused to worry and fretfulness by 
trivial or imaginary causes. 

The heart's action is also more or less increased dur- 
ing the attack. During the head-pains the face is suf- 
fused, whereas at other times his complexion is of a 
yellowish grey appearance. 

Patient has suffered from constipation for many 
years, and of late his venereal functions have exhibited 
a well-marked decline. 

I prescribed purgatives and the bromides, with 



CASES. 57 

directions lo take a hot bath as soon as the first 
symptoms of an impending attack shoukl make their 
appearance. While sitting in the bath, the warm 
water extending up to his arm-pits, I instructed him to 
press upon his carotid arteries with an implement which 
I loaned him for the purpose. These simple meas- 
ures never failed to give him instant relief. On one 
occasion he had a slight attack of syncope while in 
the bath, and the attendant, who was always present, 
removed him at once. There wei'e no farther evil 
effects from the treatment that I ever heard of , nor 
do I believe that this slight syncope need have oc- 
curred had the patient obeyed my injunction not to 
remain in the bath more than ten minntes, which for 
a man of his age was quite enough. 

By prohibiting alcohol and cutting down the patients' 
diet somewhat, the headaches were eventually entirely 
cured ; but I never succeeded in entirely abolishing a 
peculiar '^buzzing sensation in the head" (tinnitus?), 
of which the patient complained more or less while 
under my care. 

A. N. D., a young woman of twenty, consulted me 
on account of severe headaches, from which she suffers 
more or less constantly, and more especially during 
the menstrual period. She is an excellent illustration 
of that common class of head- pains which is the direct 
result of the devitalized and anaemic condition of the 
patient. For the last four years she has suffered 
from dysmenorrhoea ; her appetite is poor, and she has 
been a victim of constipation more or less during her 
whole life. Her heart's action is weak, as reflected in 
a feeble pulse, which at times is irregular. Her com- 
plexion has a tawney, sallow appearance, the conjunc- 
tiva is pale and the pupils somewhat dilated. 

The indications afforded by the carotids were also 



58 HEADACHE AND NEURALGIA. 

characteristic. When the head was thrown shghtly 
backwards so as to protrude the cervical vertebrae in 
an anterior direction, these arteries are seen to pulsate 
slightly ; but on applying the finger they are found to 
be decidedly more compressible than in healthy or 
hyperaemic individuals. When both arteries are com- 
pressed by the aid of an appropriate instrument, sen • 
sations of faintness are at once induced. On suddenly 
rising from the recumbent posture this feeling of 
faintness may also be induced, and at the same time 
the characteristic "clawing" pains of anasmia are at 
once evoked. There is some sensitiveness to light, 
but no special hyperaesthesia of the sense of hearing. 

The diagnosis in such a case as this is at once appar- 
ent : in a word, we have to do with a typical case of 
anaemic headache ; and the indications for treatment 
are the counteracting of all those features implied by 
the word anaemia. 

In the first place relief of the cerebral anaemia by 
alcohol, w^ith consequent immediate stoppage of the 
headache. 

For the purpose of further facilitating the blood- 
flow to the cerebrum, the patient is to be kept upon 
her back. 

Finally, in order to secure permanent results, the 
patient's appetite is to be stimulated by bitters, and she 
is to be put upon a course of systematic over-feeding. 
Exercise is to be studiously avoided in a case of this 
kind, at least until there is total disappearance of the 
head -pains. ToAvards the end of treatment, massage 
and general faradization may be resorted to, usually 
with great benefit. 

Nothing of the kind should, however, be attempted 
at first on account of the danger of diverting the blood- 
stream from the already impoverished nerve centres. 



CASES. 69 

Under the treatment indicated, the improvement 
in this case took place with reasonable promptness. 
At the end of a month there were no pains of conse- 
qneiice ; the patient had already gained several pounds, 
and I was able to allow her to go about a little. From 
this time forwards, her improvement was a rapid one, 
so that at the end of three months, with the exception 
of the dysmenorrhoea, she was entirely cured and she 
could take her place in society without discomfort. 

C. E T., middle-aged married lady, has suffered ever 
since girlhood from " sick-headache." 

The pain is exceedingly intense, and is generally lo- 
cated in the forehead. The attacks usually begin in 
the afternoon, but this is not always the case. Soon 
after she feels the premonitory symptom of the attack 
— a '^ dull feeling in the head "—she is afflicted by in- 
tense nausea, which is speedily followed by vomiting. 

These symptoms are invariably followed by vertigo, 
great mental depression and prostration, so that she 
is obliged to take to her bed, where she remains till 
the middle of the following day. When she is able 
to obtain relief, there is practically an end of the mat- 
ter on the following day ; but where unconsciousness 
fails to come to the rescue, there is much pain on the 
following day, and the headache may even persist for 
three days or more. 

Her complexion is sallow, her appetite fair ; but 
her digestion is habitually impaired, and she has always 
suffered from constipation. 

In her case a pill of podophylline and extr. col. 
comp. with i gr. of hyoscyamus and 1 gr. hydrarg. 
chlor..mit. never failed to give relief . In addition to 
this I am in the habit of giving her large doses of bro- 
mo-caffein combined with grain doses of the hydro- 
chlorate of cocaine, the latter being administered in 



60 HEADACHE AND NEURALGIA. 

half a tablespoonful of water, ten minutes before giv- 
ing the bro mo-caff ein. She declared that she obtained 
more prompt relief from these measures than from 
anything she had ever tried. Her tendency to diges- 
tive trouble, howevei', still remained a factor of such 
obstinacy that, with all I could do for her, I was never 
able to effect a final abolition of the attacks, which 
occurred upon the slightest indiscretion of the table, 
and even as the result of comparatively slight worry, 
where there was no history of any indiscretion what- 
ever. This is a typical case of that form of megrim 
of which every practitioner of large experience en- 
counters many cases every year. 

In giving these brief histories of the more common 
forms of intra cranial pain, I trust that I have not 
trespassed too much upon the patience of the reader. 

It is now in order to consider the second and larger 
field of our subject, the ex bra- cranial pains and those 
CO- related phases of neuralgia involving the peripheral 
nerves at large. It has also seemed appropriate to 
supplement the discussion by a chapter on that inter- 
esting and important affection known as spinal irrita- 
tion* 



PART II. 



NEUKALGIA, 



PAINS WHICH OWE THEIR ORIGIN TO 
EXTRA-CRANIAL CAUSES. 



CHAPTER IX. 

GENERAL CONSIDERATIONS. 

Under the designation of neuralgia, I propose to 
consider an affection of the nerves, the chief charac- 
teristic of which is severe and sudden pain occurring 
in one or more nerve trunks and radiating towards 
the periphery. 

Characteristics. — As Dr. Anstie' has rightly ob- 
served, the first attack is always preceded by a condi- 
tion of debility resulting from general or special causes. 
The disease is especially liable to occur in those whose 
dehcate constitutions render them susceptible to sud- 
den changes in the weather or cold draughts of 
air. This applies with particular force to persons 
of neurotic temperament, in whom the power of ac- 
commodation to violent and rapid changes of tempera- 
ture is but imperfectly developed. 

The onset of the disease is usually heralded by vague 
muscular twitch ings or sensations of pricking, quickly 
succeeded by evanescent darting pains. The pains 
are recurrent in character, and succeed each other 
with ever-increasing frequency and intensity, until, 
in the more severe attacks, the patient suffers the 
most excruciating agony. 

Sometimes the pains are described as resembling 
the sensations produced by the prick of red-hot 
needles ; at others the subject complains that he feels 
as though he were being lacerated with a saw, or as 

' "Neuralgia and the Diseases that resemble it." London, 1871. 



64 HEADACHE AND NEURALGIA. 

if electric sparks were projected along the course of 
his nerves. These pains are sometimes stationary 
and are ascribed by the subject to particular districts, 
which are found to correspond to the course of a nerve 
trunk. At other times they are ambulatory and dart 
from place to place — usually from the centre towards 
the periphery, but sometimes in an opposite direction. 
On the application of pressure above the affected nerve, 
the latter is often found to be extremely hyperaesthetic 
throughout its entire course, whereas, on the other 
hand, in a considerable number of cases exploration 
with the point of the finger reveals the existence of 
isolated painful spots — " the painful points " of Vallei. 
These painful spots are usually located at the points 
where the nerve -stems emerge from bony canals, or 
transfix fibrous tissue. They are present in the major- 
ity of cases of neuralgia, and careful digital explora- 
tion will rarely fail to result in their accurate localiza- 
tion. When exploration with the finger fails to reveal 
the presence of these piinda dolorosa, they may fre- 
quently be discovered by resort to the induced current, 
apphed by means of the wire brush. The latter should 
be gently applied along the course of the suspected 
nerve, the strength of the current being gradually in- 
creased or decreased, to suit the susceptibiUty of the 
individual. A small sponge electrode may be substi- 
tuted for the wire brush ; but I prefer the latter, pro- 
vided that the current can be acccurately regulated. 
Where the state of the nervous system is one of ex- 
treme irritability, the pains are sometimes distributed 
by irradiation to districts remote from the seat of the 
primary lesion. It has been asserted by Trousseau 
that pressure applied to the vertebrae situated at the 
origin of the painful nerves, causes pain in all neural- 
gic affections. These sensitive areas along the course 



GENERAL CONSIDERATIONS. 65 

of the cord have been designated by this author as 
" points apophysaire, or spinous points.'' ' 

It is evident, however, that tliere is nothing pathog- 
nomic in the phenomena, since they may be present 
in several affections of the spinal cord; but, neverthe- 
less, they call for special local treatment, of which 
more will be said in the Appendix on spinal irritation. 

Disturbances of sensation are frequently encoun- 
tered in neuralgia. These may consist in subjective 
feelings of numbness or formication, or the derange- 
ments of sensibility may be more marked, assuming 
the form of anaesthesia or hyperaesthesia." As a rule, 
these phenomena are more or less strictly confined to 
the district throughout which the painful nerve is dis- 
tributed. Neuralgic affections are sometimes accom- 
panied by certain reflex phenomena, which, as Rosen- 
thal remarks, may be explained by the numerous 
communications of the posterior root-fibres ^^ith the 
gray substance of the cord. Thus, in neuralgia of the 
limbs, the latter are subject to spasms which may be 
local or diffuse in character ; while in facial neuralgia 
sensory irritation gives rise to muscular contractions 
with more or less distortion of the countenance. 

Yaso-motor disturbances are frequently met with 
in neuralgia. These may consist in circulatory disturb- 
ances, properly speaking, or in cutaneous eruptions. 

^Trousseau's "Clinical Medicine," Vol. I., London, 1868. 
^ " Beitrag zur Lehre von der Hy perse sthesia und Anjesthesia/ 
von L. Tlirck, Zeitschrift d. Ger. der Aerzte zu Wien, 1850. 



CHAPTER X. 

CLASSIFICATION OF NEURALGIA. 

(1). TRIGEMINAL NEURALGIA. 

In most of the books it is the custom to designate 
the various nerve-pains according to the nerve-stem or 
branch chiefly imphcated. Thus we speak of trigemi 
nal neuralgia, supra-orbital neuralgia, etc. Following 
this well-established precedent, we may distinguish 
the following varieties of neuralgia: 

(1). Trigeminal Neuralgia with its sub-varieties. 
(a). Supra-orbital (Ophthalmic) Neuralgia. 
(6). Supra-maxillary (Infra -orbital) Neuralgia. 
(c). Infra-maxillary Neuralgia. 

(2). Cervico- Occipital Neuralgia. 

(3). Cervico- Brachial Neuralgia. 

(4). Crural Neuralgia. 

(5). Lumbar Neuralgia. 

(6). Lumbo- Abdominal Neuralgia. 

(7). Dorso-Intercostal Neuralgia. 

(8). Sciatic Neuralgia. 

(9). Plantar Neuralgia. 
(10). Coccygodynia. 
(11). Mastodynia. 
(12). Muscular Neuralgia. 

In the foregoing classification, I have purposely 
omitted the visceral pains, as their origin seems stiU too 
obscure to admit of final classification. I may add 
that the forms of nerve-pain above enumerated are of 
peculiar interest to the physician, inasmuch as they 



CLASSIFICATION OF NEURALGIA. 67 

are amenable to rational treatment of a local character, 
owing to the accessibility of the nerve-stems involved. 
Though the previous general survey of neuralgia 
affords a fair conception of the main points of interest, 
as far as the symptomatology is concerned, it will be 
well to bestow a glance upon the affection as mani- 
fested in different localities of the body. Following 
this plan, I shall adhere strictly to the classification 
of nerve-pains just given, as it is at once simple and 
sufficiently comprehensive. 

trigeminal neuralgia (neuralgia of the fifth 

nerve). 

This form of neuralgia is characterized by lightning- 
like pains, which may extend throughout the entire 
area supplied by the fifth nerve, or may confine itself to 
one or more branches of the latter. When the entire 
nerve is affected, excruciating pain is felt throughout 
the lateral half of the face and head. Sometimes these 
pains assume the form of gnawing sensations more 
or less constant in character, and extending through- 
out a wide area. At other times the pains resemble 
those induced by the electric brush, are ambulatory 
and intermittent, and are referred to by the patient 
as " flying about " or " shooting through the head." 

The painful points are observed at the localities 
where the nerve emerges from a bony canal or pene- 
trates a fascia. As in other forms of neuralgia the 
painful sensations do not always confine themselves 
to the district supplied by the affected nerve, but on 
the contrary they are projected to regions more or less 
remote from the primary seat of the affection. 

The usual vaso- motor disturbances of neuralgia are 
observed in this variety of the affection ; they consist 
in pallor and coldness of the skin in the beginning of 



<dS HEADACHE AND NEURALGIA. 

the attack, which speedily give place to a red oedema- 
tous aud glassy appearance of the integument. 

In former writings I have referred at some length 
to the violent pulsations of the carotid arteries, espec- 
ially of that on the affected side, so frequently present 
in neuralgia of the face. I would merely ohserve, in 
this connection, that if pressure he applied with skill 
to these arteries, much relief may sometimes be ob- 
tained from the distressing pains. The methods de- 
vised by myself for executing such pressure have 
already been described in the previous portion of this 
work. It must not, however, be imagined that per- 
manent relief can be obtained by such an expedient ; 
for experience abundantly teaches that a cure is alone 
to be effected by the inauguration of a profound change 
in the constitution of the nerve filaments themselves. 
I shaU refer to this portion of the subject at length in 
the chapters on treatment. 

It is not surprising that with such profound circula - 
tory disorders, there should also be present in neural- 
gia derangements of considerable magnitude. These 
may consist in the first instance in the violent swelliug 
of the face, already referred to, erysipelas, cutaneous 
eruption, inflammation of the periosteum, iritis, glau- 
coma, and in quite exceptional cases in neuroparalytic 
ophthalmia. Where the affection is at all severe, 
motor derangements assuming the form of spasms of 
the muscles of the mouth or eyelid of the affected 
side are frequently present. 

Great mental irritability and profound depression are 
almost invariably present where the affection is severe 
and has lasted for some time. As a result of this pro- 
tracted strain, it is not surprising that the subject may 
ultimately be completely prostrated or even driven to 
suicide, or the mad-house. 



CHAPTER XL 
TRIGEMINAL NEURALGIA, CONTINUED. 

MODIFICATION IN THE SYMPTOMS OF FACIAL NEURALGIA 
CONSEQUENT UPON THE RESTRICTION OF THE PAIN 
TO ONE OR MORE BRANCHES OF THE NERVE. — CER- 
VICO-OCCIPITAL NEURALGIA, CERVICO - BRACHIAL 
NEURALGIA. 

As already observed, the pain may extend through- 
out the entire territory suppKed by tlie fifth nerve, or 
may confine itself to one or more branches of the same. 
One of the most frequent of these sub-varieties of facial 
neuralgia is : 

(a). Snpra-orhital or Opldhalmic Neuralgia. — In this 
variety of the affection the pain is located in the fore- 
head, particularly in the district inmiediately above 
the affected nerve. The upper eyelid is also usually 
painful. As in the other forms of facial neuralgia, 
there is lachrymation, and congestion of the conjunc- 
tiva. Just at the point where the nerve emerges 
through the supra-orbital foramen there is a painful 
point of great constancy. This variety of facial neu- 
ralgia is usually traceable to malarial influences. The 
knowledge of this fact leads many physicians to pre- 
scribe large doses of quinine where this branch of the 
nerve is affected ; and when they have done this, they 
assume, apparently, that their duty to their client has 
been fulfilled. This seems to me poor practice, to say 
the least. My own mode of dealing with such cases 



TO HEADACHE AND NEURALGIA. 

is to first abolish the pain, by the method of local 
medication, which I shall presently describe, and then 
proceed to general measures. 

(b). Snpra-maxillary Neuralgia. — In those cases 
where all the branches of the second division of the 
fifth nerve are involved, the pain is located in the eye- 
lid, cheek, nose, upper lip, nasal cavities and gums, 
upper teeth, and in tlie zygomatic arch and temporal 
region. Sometimes^ however, the infra -orbital branch 
of the second division of the nerve is alone affected 
(infra- orbital neuralgia). Under these circumstances 
the pain is felt in the upper lip, cheek, teeth of the 
upper jaw and zygomatic arch. 

The painful points of supra-maxillary neuralgia are 
located where the nerve leaves the skull ; on the molar 
bone, on the upper lip, and in rare instances on tlie 
palate. 

(c). Infra-maxillary Neuralgia. — It is necessary in 
considering this variety of neuralgia to differentiate 
sharply between a complete or only partial implication 
of the third division of the fifth nerve. When the 
entire third division is involved, there is pain in the 
lower teeth and lower jaw, in the raucous membrane 
of the mouth, in the tongue, in the chin, in the temple 
and cheek, and in the external auditory meatus and 
auricle of the ear. . 

The more important painful points are : the inferior 
dental, situated opposite the point of exit of the 
nerve ; the temporal, located a short distance in front 
of the ear ; the parietal point, near the parietal emi- 
nence ; the lingual, on the side of the tongue ; and the 
inferior labial. When only a portion of the nerve is 
affected, the pains will of course be more or less con- 
fined to the region supplied by the branch of the nerve 
most seriously implicated. 



TRIGEMINAL NEURALGIA. Tl 

When, in facial neuralgia, the pains appear in rapid 
succession, as a distinct seizure, lasting a few seconds 
and then disappearing, but only to recur after a shorter 
or longer interval, we speak of the condition as epi- 
leptiform neuralgia. This is one of the most atrocious 
varieties of pain known to medicine, and is usually 
developed in those of well-marked neurotic tendencies. 

(2.) CERVICO-OCCIPITAL NEURALGIA. 

As a rule, the pain is confined to the region supplied 
by the great occipital nerve. The patient complains 
of pains in the occipital and posterior parietal regions, 
which, in exceptional cases, are reflected to the neck, 
brow, cheek, temple or inferior portion of the face, 
and which may therefore give rise to the supposition 
that we have to do with a true case of facial neuralgia. 
A careful search for the painful points will, however, 
usually serve to aid in the formation of a correct diag- 
nosis. The sensitive points are usually located where 
the nerve approaches most nearly the surface, but 
their situation is subject to some variation. 

(3.) CERVICO-BRACHIAL NEURALGIA. 

The pain in cervico-brachial neuralgia is perceived 
in the sub clavicular region, throughout the course of 
the upper extremity, and sometimes in the breast. 
When we consider that the five lower cervical and 
first dorsal (brachial plexus) may be wholly or partially 
involved, this wide distribution of the pains is easily 
understood. 

When the plexus is only partia,lly affected, it is 
difficult to determine what branches of the plexus or 
nerve -roots are especially involved, owing to the man- 
ner in which the nerves are interlaced. 



72 HEADACHE AND NEURALGIA. 

The painful points are quite variable ; we present a 
few of them : — A radial point at the lower external 
aspect of the fore-arm ; an ulnar point between the 
olecranon and epitrochlea ; a median cephalic point, 
at the elbow ; a shoulder point, where the cutaneous 
branches of the circumflex pierce the deltoid ; an ax- 
illary point, correspondhig to the brachial plexus. 

Eheumatism and injuries are the chief causes of this 
variety of neuralgia, just as malaria is the chief source 
of certain phases of facial neuralgia. 

I have been thus exphcit in treating of the neural- 
gias of the head, face, neck and fore-arm, because a 
proper understanding of their various phases is often of 
great value in forming a correct diagnosis, particularly 
when it is necessary to differentiate between pains of 
intra-cranial and those of the extra-cranial origin. As 
to the remaining varieties of neuralgias, I shall make 
short work of them, as they are of subordinate im- 
portance in a treatise of this character. 



CHAPTER XII. 

OTHER VARIETIES OF NEURALGIA. 

(-1.) CRURAL NEURALGIA. 

In this variety of neuralgia, the pain is felt along 
the central and inner portion of the anterior aspect of 
the thigh. The pain, following the ramifications of 
the nerve, may also extend to the lower portion of 
the limb. 

As this variety of neuralgia is not very common, 
little need be said of it, except that the painful points 
usually met with are situated near the groin, at the 
inner side of the patella and in the vicinity of the 
ankle joint. 

(5.) LUMBAR NEURALGL4. 

The pain is located in the loins, and may involve 
any or all of the first four pairs of lumbar nerves. 

(6.) LUMBO- ABDOMINAL NEURALGIA. 

Besides the loins, the mons veneris, the scrotum, 
and notably the hypogastrium are the seat of pain. 
In the more extreme cases, the gastric and sexual 
functions may exhibit more or less derangement, mani- 
fested by vomiting and involuntary ejaculations of 
seminal fluid. 

The most constant painful points are those located 
over the posterior branches of the affected nerves, 



7^ HEADACHE AND NEURALGIA. 

Other points are given in the books, but they are far 
from constant. 

(7.) DORSO-INTERCOSTAL NEURALGIA. 

In this form of the affection, the pain is located in 
the back and in the anterioi' and lateral walls of the 
thorax. When the pain in the back is the prominent 
symptom, the condition is popularly known as lum- 
bago, and it is assumed that the pains are due to rheu- 
matic or muscular causes. 

In severe cases all attempts to bend forward or back- 
ward are accompanied by great pain; while, where 
the intercostal pain is a prominent feature, respiration 
is likewise difficult and painful. The most constant 
painful points are found over the points of emergence 
of the sensory nerves from the intercostal foramina. 
Where the nerves are most superficially located, pain- 
ful points may likewise be found in most cases. 

Keurotic and anaemic persons are particularly prone 
to become the victims of this variety of neuralgia. 
Thin-blooded women, especially between the ages of 
twenty-five and fifty, are subject to it. 

The most prolific exciting cause is exposure to cold 
and damp. 

As a matter of course, pains of this character may 
be induced by neoplasms, and inflammatory and de- 
generative changes involving the vertebrae. 

(8.) SCIATIC NEURALGIA. 

In this variety of neuralgia, the pain follows the area 
of distribution of the sensory filaments of the great 
and small sciatic nerves. The subject complains of 
intense bm^ning, boring, cutting or shooting pains, ex- 
tending from the gluteal region down the posterior 



OTHER VARIETIES O^ NEURALGIA. 1^ 

aspect of the thigh and ankle to the sole of the foot. 
In exceptional cases the pain may be confined to the 
gluteal region. 

The principal painful points are located where the 
nerves emerge from the pelvis ; at the points where 
the cutaneous nerves pierce the fascia ; at a spot lo- 
cated near the head of the fibula ; an external and an 
internal malleolar point. 

A debihtated condition of the system from fevers 
or other constitutional causes, constitutes the most 
important predisposing factor. Among the exciting 
causes may be mentioned exposure to cold or damp- 
ness, and various pathological conditions of the pelvis, 
giving rise to pressure upon the sacral plexus. This 
affection is more common among men than among 
women, though I have witnessed several cases occur- 
ring among the latter, as the result of debility or some 
form of uterine displacement. In the chapter devoted 
to the treatment of neuralgia, I shall have something 
to say concerning the special measures to be adopted 
in the local treatment of sciatica. 

(9.) PLANTAR NEURALGIA. 

This form of neuralgia is characterized by intense 
pain beginning in the heel or great toe, and extending 
throughout the sole of the foot. As a rule, both feet 
are affected. Associated with the pain, there is ex- 
treme vascular distension and redness of the affected 
area. Walking increases the pain, while after the 
subject has remained in the recumbent posture for 
some time, the symptoms are greatly alleviated. 

Dr. S- Weir MitcliBll was the fii'st to give a full and 
accurate description of this affection. 

Probably the congestion of the affected area, coupled 



76 HEADACHE AND NfitfRALmA. 

with more or less neuritis of the plantar nerves, is the 
true cause of the affection. 

The affection should be treated by bathing the feet 
in solutions of carbolic acid of sufficient strength to 
cause exfoliation of the plantar epidermis on scraping 
with an ivory paper knife. Subsequently the plantar 
nerves should be medicated locally according to the 
method which I shall presently indicate in the chapter 
on treatment. While the patient is at rest, the extrem- 
ities should be kept somewhat elevated. This is best 
accomplished by elevating slightly the foot of the bed 
by means of blocks of wood of a thickness of from 
two to three inches. At first difficulty in sleeping 
will be experienced by the patient, but this is soon 
overcome, especially if a relatively high pillow be em- 
ployed. 

(10.) COCCYGODYNIA. 

This term has been applied by Scanzoni, Erichsen, 
Simpson and others, to neuralgia of the ramifications 
of the coccygeal plexus. 

The affection manifests itself chiefly by severe pain 
in the coccyx, which is greatly aggravated by sitting 
or straining at stool. Persons afflicted by coccygody- 
nia sit upon a soft cushion, or in the absence of the 
latter upon the edge of the chair. 

The affection is particularly prone to occur in women 
as the consequence of difficult or complicated labor, 
or as the result of some uterine derangement. Injur- 
ies, inflammation of the coccyx or its ligamentous 
attachments, caries and ankylosis may also cause it. 

The treatment of this form of pain by leeching, 
fomentations, baths, electricity and the like, is at 
most merely palliative. In the severer cases, relief 
must l)e sought by resort to surgery. 



OTHER VARIETIES OF NEURALGIA. 77 

An American surgeon, of Alabama, extirpated the 
coccyx in 1832 ; ' and since that time the procedure has 
been frequently resorted to. and with reason, as the 
chances of abolishing the pain by this means are much 
greater than when section of the ligaments and mus- 
cles is performed, as recommended by Simpson. 

(11.) MASTODYNIA (^'IRRITABLE BREAST"). 

This is merely a variety of intercostal neuralgia. 
The predisposing causes are the same as those of other 
forms of neuralgia. Among the exciting causes may 
be mentioned injuries of the gland, cracked or 
shrunken nipples, and tumors which press upon the 
nerves. 

The painful points are exceedingly variable, and 
are therefore of little practical moment. Spinal ten- 
derness, especially in the region of the upper dorsal 
vertebrae is, however, fairly constant. 

Where the cause is manifest, it should be removed 
as speedily as possible ; and meanwhile the patient 
should be relieved by the administration of opiates. 

(12.) MUSCULAR NEURALGIA. 

Both physician and patient have long been in the 
habit of referring certain painful sensations to the 
muscles. The muscles most frequently involved are 
those of the back and neck ; and inasmuch as these 
muscle-pains frequently exist quite independent of 
any exaggeration of cutaneous sensibility, the popular 
mode of regarding them as due to an abnormal condi- 
tion of muscular sensibility seems justified. 

The same methods of treatment to which resort is 



American Journal of tlio Medical Sciences,'' III., 1883. 



7B HEADACHE AND NEURALGIA. 

had in cutaneous neuralgia, may, with slight modifica- 
tions, be employed in combating these hypersesthetic 
conditions of the muscles. 

These, then, are the varieties of neuralgia most fre- 
quently encou Qtered in practice. 

In the succeeding chapters, I shall enter into a con- 
sideration of the causation, diagnosis, pathology and 
prognosis of neuralgia, as a preliminary to the discus- 
sion of the various factors involved in treatment. 
This latter portion of the subject is evidently of the 
first importance ; and I shall therefore offer no apology 
for devoting much space to its elucidation. 



CHAPTER XIII. 

CAUSATION. 

There is no doubt that hereditary influences occupy 
a conspicuous place among predisposing causes. As 
previously observed, those who have received from 
their progenitors sickly constitutions or pronounced 
neurotic tendencies frequently become the victims of 
periodic neuralgias. This liability to transmission, 
v^hich is a pronounced characteristic of nervous disor- 
ders in general, is particularly well exemplified in 
the various forms of mental derangement. 

It is a well known fact that in those diseases the 
hereditary taint often affects the mental integrity of 
many generations ; comparatively trivial causes being 
required to evoke active mental alienation in individuals 
who have inherited the insane diathesis. A similar 
state of things is often observed in connection with 
neuralgia. Fathers and mothers afflicted with neu- 
ralgia frequently transmit a predisposition to this or 
some other form of nervous derangement to their 
offspring, and the latter in their turn bequeath the 
morbid tendency to future generations. 

The most severe varieties of the affection are ob- 
served among those in whom the vital forces have 
been greatly curtailed through the agency of wasting 
diseases or general mahiutrition. Anstie ' has assumed 
a hereditary weakness of the gangha of the posterior 
columns, which, when subjected to protracted centri- 

' "Neuralgia and Diseases that Resemble It." London, 1871. 



So HEADACHE AND NEURALGIA. 

petal irritation becomes the seat of interstitial atrophy. 
For my own part, I cannot accept this hypothesis, 
since if in all cases of neuralgia such a serious lesion 
were present, it would be difficult to conceive of cures 
taking place at all. 

As is well known, not a few cases of the affection 
3"ield to hyper-nutrition and local treatment, a fact 
difficult of explanation, if a jiositive destruction of 
nerve cells be conceded to be an invariable concom- 
itant of the affection. Climatic peculiarities exercise 
a marked influence upon the evolution of neuralgias. 
The most favorable season for the development of the 
affection is during the cold, damp months of the year. 
Sudden changes in temperature, as already noted, 
are particularly jDrone to develop an invasion of the 
disease. Exposure to cold and violent winds, as well 
as residence in damp, dark, and badly ventilated 
dwellings, is liable to cause an attack of neuralgia, 
which has a marked tendency to become chronic, un- 
less a change of climate be immediately sought. 

Previous to marriage, females are, on the whole, 
more liable to the affection than men. 

The neuralgias which frequently follow chronic 
pulmonary affections, chlorosis, and other debilitating 
maladies, are the result of inability on the part of the 
vitiated blood to adequately nourish the peripheral 
and central nervous system. 

The characteristic lancinating pains of neuralgia 
are often observed in conjunction with disturbances 
of the central as well as peripheral nervous system. 
It has been affirmed that certain congestive cerebral 
conditions may give rise to neuralgia, and the associa- 
tion of the disorder with tumors, softening or sclerosis 
is not uncommon, A number of inflammatory affec- 
tions of the cord are accompanied at the outset by 



Causation. 81 

neuralgic symptoms ; the lancinating pains of ataxia 
are a good illustration of this. It is i)i'obable that the 
dyscrasic and toxic forms of neuralgia owe their ex- 
istence to the effects of the deleterious substances upon 
the nerve cells of the posterior columns. At all events 
this seems a more plausible supposition than the 
pathological hypothesis of Anstie, already referred to. 
The peripheral causes are those which most concern 
us here, since they constitute the etiological factor 
most frequently encountered among cases commonly 
designated as neuralgia. In this category belong : (1.) 
causes which, acting upon the periphery of the nerve, 
cause compression of the latter. Thus caries and 
periostitis involving the foramina of bones, through 
which the nerves pass, may cause a sufficient degree 
of constriction to set up inflammation of the neuri- 
lemma. (2.) Rheumatic influences, affecting the nerve 
fibres of muscles and joints. (3.) Foreign bodies and 
growths, such as syphilitic gummata, tumors and 
aneurisms, (tt.) Congestive and inflammatory condi- 
tions of nerve-sheaths. (5.) Finally there are certain 
neuralgias which owe their origin to irradiation and 
reflex causes. 
6 



CHAPTER XIV. 

DIAGNOSIS. 

The proper differentiation of the central from the 
peripheral varieties of the affection is evidently a mat- 
ter of consequence from a prognostic point of view. 
To summarize briefly the requisites of such discrimi- 
nation, it may be stated, in the first place, that where 
central causes are suspected a careful analysis of the 
condition of the brain and spinal cord should be under- 
taken, both by means of objective observation and 
interrogatories addressed to the patient himself. If 
we thus, for example, diagnosticate with reasonable 
certainty hyperemia, inflammation or softening of 
the brain or spinal cord associated with *' neuralgi- 
form ' ' pains, and if, at the same time, we are unable 
to discover any defect of the peripheral nervous ap- 
paratus, we are justified in concluding that the central 
disorder is the true cause of the pains, which, m accor- 
dance with the laws of eccentric projection, are referred 
to the periphery. 

When frontal headache, reflex contractions of the 
face, with lacerating pains along the course of certain 
nerves and hyperaesthesia, are associated with well- 
marked psychical disturbances, the suspicion that the 
neuralgia is of cerebral origin is justified. When 
facial neuralgia co-exists with ambulatory-pains in 
the hmbs and neck, associated with vertigo, periodic 
headache, convulsions, evidence of neuroretenitis, and 
paresis of various cranial nerves and eventual para.ly- 



DIAGNOSIS. 83 

sis of the extremities, we have presented unmistakeable 
evidence of cerebral tumor. 

The symptoms which point to the spinal origin of 
neuralgia are : early formication in the toes and fin- 
gers, numbness, sensations of cold, periodic rachialgia 
and brachialgia, lancinating pains along the course of 
the sciatic nerve with cutaneous hyperaesthesia, in- 
equahty of the pupils, diplopia, irritation of the sexual 
organs, fatigue on slight exertion, extreme excitability 
to the electric currBnt in certain circumscribed locali- 
ties, and susceptibility to moisture and variations of 
temperature. 



CHAPTER XV. 

PATHOLOGY. 

The older pathologists were in the habit of describ- 
ing '^scorbutic," ^^ rheumatic," ^'scrofulous," and 
" arthritic " forms of neuralgia. Among more recent 
writers, however, it has become fashionable to attrib- 
ute the pain experienced in these and certain consti- 
tutional affections to secondary causes, such as disease 
of the blood-vessels, congestion or inflammation prop- 
agated to neighboring blood-vessels/ etc. 

The hysterical variety of neuralgia is usually charac- 
terized by the ambulatory nature and variable inten- 
sity of the pains, which usually follow upon hysterical 
convulsions or violent mental excitement. 

The agency of syphilis in the production of the af- 
fection has long been recognized. In all probabihty 
the dyscrasia is capable of causing the characteristic 
neuralgic pains by the inauguration of changes in the 
central or peripheral nervous system or both. Thus 
chronic inflammatory processes located in the blood- 
vessels and connective tissue may affect the cord 
and jieripheral nerves as well, thus giving rise to 
neuralgiform pains. Or, osteal and periosteal dis- 
eases may affect the peripheral nerves in their transit 
through bony foramina, producing constriction or in- 
flammation, and thus causing violent pains. 

In a comparatively recent publication, Fournier'' 

' See Article by Erb, Zieinssen's Cyclopedia, Vol. XI. 
'^ Legons siir la Syphilis, 1873. 



PATHOLOGY. 85 

has drawn attention to the typical varieties of neural- 
gia which occur in women during the secondary period 
of syphiHs, and which evince a marked predilection 
for the supra-orbital and sciatic nerves. The mucous 
membranes of the stomach, rectum, urethra and intes- 
tine are frequently the seat of neuralgiform pains ; 
when thus situated the latter usually point to an hys- 
teria or central affection. 

There are a number of toxic substances which, 
when introduced into the system, may give rise to 
more or less severe neuralgic affections. In this cate- 
gory belong lead, copper, and mercury. Persons who 
have contracted sypliilis, a,nd w^ho have subsequently 
become thoroughly mercurialized, frequently develop 
an obstinate form of neuralgia. Alcohol and tobacco 
when employed to excess may also give rise to neural- 
giform symptoms ; but the precise manner in which 
these toxic agents act is still, to a considerable extent, 
enveloped in obscurity. 

The influence exercised by lead in the production of 
neuralgic affections has long been understood, and 
hence the designation lead arthralgia, lead colic, etc. 



CHAPTER XVI. 

PKOGNOSIS. 

The first step of importance in predicting with rea- 
sonable probability the prospect of cure in neuralgia, 
is an accurate determination of the exciting cause. 
Where the latter consists in an organic affection of 
the brain or spinal cord the prognosis is unfavorable, 
in the majority of cases ; and the most that can be 
obtained is a temporary alleviation of the symptoms. 
The same may be said of those cases which are attrib- 
utable to permanent organic changes of structures 
contiguous to nerve stems. Thus the neuralgic affec- 
tions resulting from osteal and periosteal diseases, tu- 
mors and remote and inaccessible cicatrices are practi- 
cally incurable. On the other hand, those varieties 
of the affections which result from malaria and syphi- 
lis are exceedingly amenable to treatment, and the 
prospect of ultimate recovery in such cases is good. 

As a rule, then, peripheral neuralgias offer a far better 
prognosis than those which result from organic affec- 
tions of the central nervous system. When the source 
of peripheral irritation has been removed recovery 
usually ensues ; but it is hardly necessar}^ to draw at- 
tention to the well-known liability to relapse which 
asserts itself when the patient is unduly exposed to 
sudden variations of temperature. The prospects of 
recovery are more favorable in men than in women. 
Moreover, the question of age is of no little importance 
in determining the prospects of recovery ; and it may 



PROGNOSIS. S7 

be stated in general terms that the prognosis is i;jecid- 
edly better among the young than in those of advanced 
life. 

The occurrence of atrophic changes, anaesthesia or 
paralysis in the course of the affection may be regarded 
as a sign of ill-omen as far as the chances of ultimate 
recovery ai-e concerned. 

Where the iDiinda dolorosa persist, after the pain 
has subsided, the prospect of a relapse is greatly in- 
creased. In the majority of cases the immediate dan- 
ger to hfe may be regarded as nil. Sometimes, how- 
ever, where the general constitution is feeble, and 
where the symptoms have persisted for a long time, 
the strength of the subject finally gives way, and death 
ensues from marasmus o]^ some intercurrent affection. 

Neuralgia in its most severe form has frequently 
been the cause of suicide ; a case of this kind recently 
occurred in New York City. Even where the condition 
of the patient is not so desperate these atrocious face- 
pains necessarily seriously jeopardize the success and 
happiness of their unfortunate victim ; and, as ah'eady 
intimated, they sometimes cause permanent mental 
trouble. 



CHAPTER XVII. 

TEEATMENT IN GENERAL. 

As a matter of course, it is of importance to ascer- 
tain the exciting cause in each case, and, by the re- 
moval of the same, insure a i^ermanent cessation of 
the neuralgic symptoms. Unfortunately, however, the 
discovery of the predisposing cause was in former 
times a much easier matter of attainment than the 
subsequent removal of the pain when it had once be- 
come firmly established ; this at least was the case 
previous to the discovery of the analgesic properties 
of antipyren and cocaine, and the methods of pro- 
longing the action of the latter drug. As I have 
devoted considerable time and study to the devel- 
opment of the capabilities of the last mentioned 
remedy in the treatment of painful nervous affec- 
tions, and as, moreover, the methods which I have 
devised enable the physician to accomplish much 
with exceedingly small doses of the drug, I shall pres- 
ently describe at length the various features involved 
in this mode of local treatment. Let me state, how- 
ever, before proceeding further, that I always arrest 
the local pain as far as possible, by resort to those 
methods of local medication, before seeking to remove 
the more remote constitutional causes. 

Thus while our resources must, to a considerable 
degree, be directed towards the local symptoms, we 
should not fail, at the same time, to combat the obvious 
predisposing factors as far as possible, especially when 



TREATMENT IN GKNKKAL. 89 

the latter are of a more or less constitutional character, 
and consequently proportionately amenable to treat- 
ment. Thus, in consonance with these views, if the 
subject, in conjunction with neuralgia is likewise a 
sufferer from general aniemia, a causal relation between 
the two diseases may be assumed to exist, and accord- 
ingly energetic constitutional treatment should be em- 
ployed in conjunction with proper local medication. 
When scrofulosis, gout, tuberculosis and syphilis are 
found associated with neuralgia, appropriate medicinal 
and dietetic measures should be directed against the 
dyscrasic condition, and reliance should, under no 
circumstances, be entirely placed upon local symp- 
tomatic treatment. Where the neuralgia occurs peri- 
odically and its appearance is demonstrably associa- 
ted with malarial influences, quinine should be given 
in large doses. 

As I have said, however, we should relieve the local 
pain before resorting to this or any other mode of con- 
stitutional treatment. Sometimes a few doses of qui- 
nine are beneficial, but I cannot agree with a well- 
known writer, that such brief medication is siifficient 
to cause permanent disappearance of the pain-provok- 
ing condition. In the majority of cases it is well to 
continue the use of the drug for several days or weeks. 

Even when the malarial condition has apparently 
yielded to treatment, and the pains have ceased to 
recur, a short sojourn in a malarious district is quite 
sufficient to cause a relapse. If, by careful scrutiny 
of the history of the case, it be possible to discover a 
toxic influence, such as that induced by the introduc- 
tion of lead, mercury or alcohol into the system, ap- 
propriate means should be employed for removing the 
foreign substance from the economy. 

Among the less-comphcated causes of neuralgia are 



00 HEADACHE AND NEURALGIA. 

wounds, cicatrices, the presence of foreign bodies of 
various kinds and the mechanical effects produced 
by the compression of nerve-stems by impacted fecal 
masses, periostitis, tumors and cicatricial tissue depos- 
ited as a result of previous inflammatory or traumatic 
causes. In those cases which are directly attributable 
to rheumatic causes, good results are obtainable from 
the employment of the Turkish or vapor baths; but, as 
a rule, not much is to be gained by the local applica- 
tion of blisters and sinapisms. The iodide of potassium 
may also be given, and the resort, during the winter 
months, to a mild and equable climate, wiU often prove 
of considerable benefit. When neuritis can be clearly 
diagnosticated as the exciting cause of the affection, 
derivation by means of the bowels and skin should 
be employed, and resort may also be had to local ap- 
plications of cold and dry or wet cups. 

Better than all these, however, in well-marked neu- 
ritis, is the local medication of the nerve -filaments, al- 
ready referred to, and which I shall presently describe 
at length. 

In the cases which owe their existence to a primary 
organic affection of the brain or spinal cord, but httle 
of permanent good can be anticipated from treatment. 
As already intimated, treatment in such cases must 
of necessity be addressed more or less directly to the 
symptoms themselves, and above all to the problem 
of attaining, from time to time at least, a temporary 
abatement in the intensity of the pains. Electricity, 
hydrotherapy and the various opiates, particularly 
antipyren — or, if absolutely necessary, morphia — are 
our best aids under the circumstances. 

Among the various remedies which have been em- 
ployed, with a view to combatting pain in all its forms, 
and particularly severe intra or extra- cranial pain, 



TREATMENT IN GENERAL. 91 

not one is more deserving of our confidence than anti- 
pyren. At the meeting of the Academie de Medicine 
at Paris on the 23d of August, 1887, M. Germain See 
drew attention to the valuable analgesic quality of 
this drug, especially in headache, migraine and face- 
ache. The cases Avhicli he presented on this occasion 
showed in a striking manner the potency of this re- 
markable drug to relieve suffering/ 

Subsequently this gifted clinician showed ' how pow- 
erful are the analgesic effects of this remedy in acute 
and chronic articular rheumatism. 

This is not the place to enter into a protracted dis- 
cussion of the physiological effects of the remedy. 
Enough, that we have seen M. See's statements con- 
firmed again and again, so that at the present time 
it would be difficult to find a practitioner who has not 
had occasion to endorse to a great extent that which 
has been affirmed for this admirable remedy as an 
antidote to pain in many of its phases. 

For my own part, I would merely state that I have 
used antipyren not only in all forms of intra and 
extra- cranial pain, but in spinal irritation and spinal 
concussion as well, with excellent results, and more 
particularly when given in conjunction with local ex- 
pedients, such as injections, refrigeration and the like. 
I have also witnessed most striking results from its 
use when combined with relatively minute doses of 
morphine. 

This experience with the remedy has confirmed the 
belief that in antipyren we have one of the most val- 
uable, and at the same time safe, drugs ever introduced 



^ L' Union Medicale, Troisieme ISerie, Vol. XLIV., page 273, et 
seq., 1887. 
^rUnion Medicale, Troisieme, Serie, Vol. XLIV., p. 349, 1887. 



92 HEADACHE AND NEURALGIA. 

to the profession. I shall have occasion to refer to 
this useful drug hereafter. 

Having said this much in a general way regarding 
the points to be kept in view in any rational system 
of therapeutics, it now remains to describe the methods 
by which it is possible to submit the painful nerve 
and its branches to the action of various potent reme- 
dies, such as cocaine, pyrogallic acid, aconite, etc. 

From my o^^m experience, as well as from that of 
other physicians who have occupied themselves with 
the subject, I cannot help feeling that this mode of 
treatment constitutes one of the most powerful means 
at our disposal for directly combatting these neuralgias 
of the face, whatever their remote origin may be. 

To the end that the various details involved in this 
mode of neural medication may be the better under- 
stood, I shall preface the description of the individual 
steps of the procedure by a few considerations of a 
somewhat general character. 



CHAPTER XVm. 

LOCAL MEDICATION OF NERVES. 

OF REMEDIES WHICH ARE ADAPTED TO THE MEDICATION 
OF NERVES. 

It is not my intention on the present occasion to 
enter into an extended discussion of the intricate phar- 
maco-dynamical questions involved in the treatment 
of affections of the peripheral nerves. 

To do this would presuppose an intimate knowledge 
of the chemical constitution of nerve tissue ; and such 
knowledsre is, in the present state of medical science, 
denied us. While we cannot, therefore, know what 
chemical reactions are produced by the contact of a 
given medicament with the substance of a nerve, we 
can at least take cognizance of any considerable 
modification in the function of the latter thereby in- 
duced. 

Adopting this mode of regarding the question, we 
find that, with the remedies and methods at our dis- 
posal, we are able to accomphsh three things. We 
may temporarily suspend the conduction in a nerve ; 
or we may change its constitution to such a degree as 
to more or less permanently interfere with the trans- 
mission of impression through the same, or finally we 
may destroy the nerve filaments altogether. The first 
problem is best accomplished by the use of cocaine ; 
the second by the aiDplication of chloroform or ether, 
immediately after the cocainization of the nerve, or 



9i HEADACHE AND NEURALGIA. 

by mechanical aids for a certain length of time, and 
the last by the use of acids or the knife. 

The first mode of procedure is that which I prefer in 
cases of moderately acute nerve-pain, reserving the 
second method for exceptionally obstinate and chronic 
cases. As to the last method, it should not be resorted 
to except in exceptional cases. 

It will therefore be my object on the present occa- 
sion to show first how remedies may be best introduced 
into the immediate vicinity of painful nerves, and 
how their benignant action upon the latter may be per- 
petuated. 

METHOD OF INTRODUCING COCAINE INTO THE SKIN ABOUT 
THE FACE. 

First of all it is necessary to ascertain what branch 
or branches of the fifth nerve are affected. To this 
end the patient should be carefully interrogated as to 
where the painful sensations are located, and after- 
ward a careful digital exploration undertaken by the 
physician, with a view to discovering any painful points 
in the continuity of the nerve- stems which may serve 
as a guide to a more accurate diagnosis. 

Having thus determined what are the offending 
branches of the nerve, it only remains to introduce 
the medicament into the painful territory. This may 
be accomplished with great ease and accuracy about 
the face, on account of the superficial location of the 
sensory nerves. Moreover, by the aid of the method 
which I am about to indicate, it may be achi-eved ab- 
solutely without pain or inconvenience to the patient. 

The procedure, then, which I have found effective 
for the purpose is as follows:' — The region to be 

' "New York Medical Journal," Vol. XLIV., Nov. 10, 188G. See 



LOCAL MEDICATION OF NERVES. 05 

anaesthetized is first perforated by means of a delicate 
instrument provided with a large number of fine nee- 
dles. There is no pain in the simple manipulation, as 
the needles, being released, are driven into the skin so 
quickly that there is no sensation whatever. Again, 
it is necessary to allow the needles to penetrate be- 
yond the epidermis. 

Having thus increased the porosity of the skin so 
as to admit of the passage of the medicament into 
its deeper layers, it only remains to introduce the same 
as speedily as possible. This is best accomplished by the 
aid of the galvanic current. A sponge electrode, satu- 
rated with a solution of cocaine of appropriate strength 
(5^), is secured by means of an elastic band over the per- 
forated territory. This electrode is then attached by 
means of a reophore to the positive pole of a galvanic 
battery. A similar electrode saturated with warm 
water is secured as near as possible to the first sponge, 
hut ivitJiout touching it, and is then connected with the 
negative pole of the battery by an appropriate conduct- 
ing cord. It now only remains to so regulate the 
switch board that from four to six cells are brought into 
operation. As for myself. I usually begin with three 
cells, gradually increasing the strength of the current 
until five or six cells are brought into requisition. 
By adopting this policy there is no inconvenience from 
the action of the current. Unless a slight acid taste can 
be described as such. 

also Webster, David, M. D., on Coming's method, "Medical 
Record,'' March 5th, 1887. 

Benjamin Richardson, of London, was the first, so far as I 
know, to induce local anaesthesia by the use of a chemical in 
conjunction with a galvanic current. Subsequently AVagner 
employed the same method in conjunction jwith cocaine. I im- 
proved Richardson's procedure by introducing the principle of 
preliminary painless puncture of the skin. 



96 HEADACHE AND NEURALGIA. 

It is quite impossible to lay down infallible rules as 
to the length of time which it is expedient to allow 
the current to operate, since much must depend upon 
the strength of the battery and the extent of the terri- 
tory which it is desired to medicate. At all events ten, 
or at most twenty minutes will usually be sufficient ; 
and should the pain not yet have subsided, a supple- 
mentary injection of a three -per-cent solution of the 
remedy may be resorted to. As a rule, however, the 
pain will be found to have left the part after the cur- 
rent has operated for eight or ten minutes. 

The prolongation of the action of the medicament 
is of great importance in the treatment of neuralgia, 
as we are thereby enabled to expose the affected nerve 
filament for a long time to the influence of the remedy. 
That the chemical action of the latter upon the painful 
nerve filaments is thereby immeasurably increased, 
is beyond question. This prolongation of the effects 
of the remedy may be accomplished in a twofold 
manner, to wit : (1.) By the employment of certain 
mechanical appliances, and (2.) by resort to certain 
potent chemical agents, (chloroform, acids, ether, etc., 
etc.) I shall describe at once the first (mechanical) 
mode of procedure, as it is at once simple and effi- 
cacious. 



CHAPTER XIX. 

LOCAL MEDICATION OF NEKVES, CONTINUED. 

THE PROLONGATION OP THE LOCAL ACTION OF THE 
REMEDY. — author's METHOD. 

When cocaine is employed about the extremities it 
is an easy matter to perpetuate its action to any rea- 
sonable extent. We have only, in fact, to suspend 
the action of the arterial and venous circulation, as I 
have long since shown ' by the aid of an appropriate 
bandage. By this simple means we are enabled to keep 
the anaesthetic for any reasonable time in contact with 
the nerve filaments : for, the circulation in the part 
being suspended, the blood cannot wash away the an- 
aesthetic into the general circulation. Likewise, about 
the breast and back, we can accomplish, though in a 
much more imperfect manner, a similar condition of 
affairs by resorting to compression by the aid of rings, 
clamps and the like. When, however, we desire to 
perpetuate the action of the drug about the face the 
problem is wholly different, since these mechanical 
devices are not available. To meet this difficulty I 
have devised the following mode of procedure : " 

' See also Wyeth, John A., on Coming's method of inducing 
cocaine ansethesia ('A Text-book on Surgery," New York, 1887, 
p. 22.) Also Smith, Stephen, on Coming's method, "Principles 
and Practice of Surgery," Philadelphia, 1887, p. 54 e^ ^eg. See 
other communications on the same subject by J. R. Conway, J. 
Williston Wright, Robert F. Weir, M. J. Roberts, and others . 

^ ' ' The Medication of Nerves, and its Application in Treatment 
7 



98 HEADACHE AND NEURALGIA. 

Having introduced the anaesthetic throughout the 
painful territory, according to the method previously 
described, I place over the part a piece of fine wire 
gauze (Fig. V.), which is trimmed with a pair of scis- 
sors so as to exactly cover the medicated zone. A 
T-shaped block of wood is then placed upon the wire 
gauze, and a considerable degree of pressure applied, 
by means of an elastic strap which encircles the head 
and is secured in place by means of a buckle (Fig. YI.). 
As a result of this procedure the wire gauze is pressed 
well into the skin, and the septa of the same cause oc- 
clusion of the subjacent capillaries, but without press- 
ing out the cocaine, which remains caught, as it were, 
in the meshes of the wire gauze. By this method I 
have often produced a state of complete anaesthesia 
lasting an hour and a half. It is not surprising, there- 
fore, that such a protracted exposure of the nerve fila- 
ments to the chemical influence of the drug should 
often of itself result in a permanent abolition of the 
painful sensations. Where the pain is located above 
the eyes, as in supra-orbital neuralgia or in the temj)le, 
this mode of treatment acts like magic. 

A slight modification in the mode of procedure is 
necessary, especially in emaciated subjects, when the 
pain is more diffuse, extending to the cheeks and lower 
portion of the face. Under these circumstances, I am 
in the habit of first tamponing the cheek, which is 
readily accomplished by 23acking the face between the 
alveolar processes and the cheek Avith small pledgets of 
cotton. The cheek being thus distended, it is easy to 
press the wire gauze upon the skin Avith sufficient 
force to cause occlusion of the subjacent capillaries. 

of I!^euralg:ia and other Painful AfTections.^' A iDaper read before 
the Medical Society of the State of New York, Feb. 1st, 1887. 
Published in the "Medical Record " for March 19th, 1887. 



LOCAL MEDICATION OP NERVES, CONTINUED. 



1)9 



I can truly say that this plan of treatment has 
yielded better results in my hands than I have been 
able to obtain by the aid of that polypharmacy which 
has been so fashionable during the last thirty years. 

Sometimes, in uncomplicated cases, one application 



HAZARD. HAZARD, ac en. w.r.raRo 



■Isia "Sf 5 Sii .iSS' S^^^^ 






•HHKKisBKs:-::::" 



mmm 



rTTTT 
Fig. 5.— Showing the kind op Wire Gauze to be Employed. 




Fig. 6.— Showing Application of Gauze Block and Elastic Strap, for 
Relief of Pain in Temporal Region. 



is sufficient to abolish the pain for weeks or even 
months. In others, again, the pain may return after 
a few days, but with less intensity. All that is then 
necessary is to repeat the procedure, as the punctures 
are so small as to leave no scars behind, hyperaemic 



100 HEADACHE AND NEURALGIA. 

spots about these minute openings disappearing within 
a few days, as already observed. Constitutional treat- 
ment should usually be continued side by side with 
these local measures, so that the nutritive conditions 
of the organism at large being improved the affected 
nerve-stems may also take part in the general ame- 
lioration. 

I will merely add that having produced an anaes- 
thetic zone of the desired extent, sach remedies as 
chloroform, ether, aconite and pyrogal]ic acid may be 
injected without the slightest pain or inconvenience. 
The effects of these remedies upon the nerve-filaments 
may then be prolonged to any extent by the applica- 
tion of the gauze, block and strap. 

So much then for prolonged local medication of the 
nerves — a method which has already accomplished 
and will undoubtedly continue to accomplish much 
in a department of neurology where unfortunately but 
little of practical moment has heretofore been achieved. 

CASES. 

Although an extended recapitulation of the details 
of the clinic would be a work of evident supereroga- 
tion in a monograph of this character, I may perhaps 
claim the indulgence of my professional readers if I 
take the liberty of citing a few illustrations of the 
more important phases of neuralgic pain. 

Let us begin, then, by giving the principal points in 
some cases of sciatica which I have treated principally 
by the aid of local measures. 

Before proceeding to details, however, I would 
again call to mind the fact that three years ago I 
brought to the notice of the profession' certain re- 

1 "New York Medical Journal/^ Sept. 19th, 1885. 



LOCAL MEDICATION OF NERVES, CONTINUE^. 101 

searches through the instrumentality of which I ascer- 
tained a variety of facts of both medical and surgical 
importance. In the first place, I conclusively demon- 
strated that the suspension of the arterial and venous 
circulation in a part into which such an anaesthetic 
as cocaine has been injected is sufficient to prolong 
the anaesthetic effect for any length of time. 

Secondly, I showed that when the precaution of sus- 
pending the circulation has been observed, it is no 
longer necessary to employ strong solutions of the 
anaesthetic ; but, on the contrary, the strength of the 
latter may be reduced to an incredible extent, and 
yet anaesthesia of the part be induced and definitely 
protracted. The significance of these facts was at 
once appreciated by a large number of surgeons ; and 
soon medical literature in both this country and 
Europe began to teem with the accounts of numer- 
ous operations, more or less extensive, in which my 
method of inducing local anaesthesia had been re- 
sorted to with excellent results. After these reports of 
successful operations had continued to appear for sev- 
eral months, giving rise to continuous comments both 
in this country and Europe, I decided to select some 
of the more noteworthy of these cases, and to embody 
the same in book form. At the same time I availed 
myself of the opportunity afforded by this publication 
to elaborate the technique of my method, so as to 
make it almost universally available. ('' Local Anaes- 
thesia," by J. Leonard Corning, M. D., New York: D. 
Appleton & Co. 1886). The reception by the medical 
press and the subsequent large sale of this book have 
convinced me that my endeavors in the cause of scien- 
tific medicine have been amply appreciated by my 
colleagues in the profession. All this is, of course, 
gratifying. Still, while I was glad to have rendered 



U)2 HEADACHE AND NEURALGIA. 

service to such of my colleagues as are engaged in the 
practice of surgery, it was but natural that the desire 
should have been rife, in one interested in neurological 
medicine, to make the method of some use in that 
branch of practice. Indeed, I v^ill admit at once, 
that, at the very beginning of these labors, I saw 
certain possibilities in this direction, particularly in 
the treatment of derangements of the peripheral 
nerves. Thus, in my original paper, I said : ^ ^ In the 
treatment of neuralgias, and other disorders of the 
peripheral nervous system, it (my method) is, I believe, 
destined to render good service." For some time 
these scientific anticipations remained without fruit 
of a practical nature ; for, indeed, my professional en- 
gagements had been such that I wa,s unable to follow 
them to a practical sequence. Some time since, how- 
ever, I was able to put these ideas to a practical clini- 
cal test, and it is with a view to reporting the results 
more fully that I have indulged in these reminiscences. 

The first case in which I put my method to a test 
was one of sciatica of long standing. The history of 
the case, and its treatment by me, is briefly as follows : 

B. F., woman of 45 years, single, of feeble neurotic 
temperament, came under my care some time since. 
On making a careful examination, I found the follow- 
ing condition of things : She had long suffered from 
uterine displacement, caused, as I was informed, by 
an attempt to lift the end of an upright piano. From 
this time forth her health had gradually failed ; she 
had lost flesh, her appetite had become poor, her sleep, 
which was never of the best, had deteriorated to such 
a degree that, as she expressed it, she was ''never 
wholly unconscious," her menstruation was painful 
and irregular, and she suffered from a morbid appre- 
hensiveness, exhibiting itself in a dread of aU society 



LOCAL MEDICATION OF NERVES, CONTINUED. 103 

and ill an inability to sleep without a light in her bed- 
room. The cliief cause of her distress was, however, 
a violent neuralgia of the right sciatic nerve, which 
Avas not benefited by any of the various forms of uter- 
ine support. From this she had suffered, at intervals, 
for the past fifteen months. On examination, many 
l^ainful points were found along the course of the 
nerve ; the limb was maintained in a partially flexed 
condition most of the time ; there was considerable 
cutaneous hyperaesthesia, but no anaesthesia ; the pain, 
which was intense during the day, was greatly aggra- 
vated at night, and the mere touch of the bed-clothes 
was often sufficient to cause an intense paroxysm ; 
the affected limb was pale and cold to the touch, the 
relative difference between the healthy and affected 
side being great. 

The physician under whose care she had been pre- 
vious to consulting me, had, very justly, as it then 
seemed to me, attributed the sciatica to the uterine 
displacement, and had accordingly applied a pessary. 
This treatment had, however, afforded her absolutely 
no relief. Subsequently galvanism, the actual cau- 
tery^ blisters, hot and cold fomentations, the Turkish 
and Russian baths were all essayed, but without any 
considerable benefit. 

When I first saw her she was suffering from a par- 
oxysm of unusual severity, so that short periods of 
sleep were only obtainable by the use of copious mor- 
phine injections. The latter were made over the pain- 
ful points along the course of the nerve ; but what 
little rehef the patient thus obtained was but tempo- 
rary. All usual measures having failed, I finally had 
recourse to the following procedure : 

I injected one hundred minims of a i^-solution of 
cocaine at two of the more painful points along the 



l04 HEADACHE AND NEURALGIA. 

course of the nerve, and immediately thereafter ap- 
phed a tourniquet in such wise as to interrupt the cir- 
culation in the crural artery, above the point of injec- 
tion. As a rule, I believe, the tourniquet should be 
placed as high up as possible. In this case it was lo- 
cated as near Poupart's ligament as was consistent 
with the retention in place of the instrument. 

During the first five or ten minutes little relief was 
experienced, but after the lapse of twenty minutes the 
pain had sensibly diminished, and in half an hour it 
had entirely disappeared. The patient complained 
somewhat of the pressure of the bandage, but this 
was relieved by placing a small roll of cotton under 
the tourniquet, where the latter passed over the nerve- 
stem. The tourniquet being removed, she declared 
that she felt no pain, even after the lapse of eight or 
nine hours. On the morning following the treatment 
there was, however, a return of pain . I immediately 
made the injections and applied the bandage as before. 
This time, after the removal of the tourniquet, there 
was no return of pain for four days. Without enter- 
ing further into details, I may state that for three 
weeks this mode of treatment was persisted in, the 
incarcerated injections being resorted to whenever there 
was a recurrence of pain. The periods of exemption 
became longer and longer, until the pain finally left 
her, apparently for good. It is now four months since 
the last injection, and there has been no return of pain. 

The second case in which I resorted to this method 
of prolonged medication was that of a lady of sixty- 
five, who was likewise a sufferer from sciatica of many 
years standing. In her case the usual expedients had 
been resorted to, but with little or no avail. 

As in the previous case, I made copious and deep 
injections of solutions of the hydrochlorate of cocaine, 



LOCAL MEDICATION OF NERVES, CONTINUED. 105 

incarcerating the medicament by the appKcation of 
the tomuiiquet above the point of injection. This pro- 
longed contact of the medicament with the nerve-stem 
proved ahiiost as salutary as in the previous case, but, 
owing to the long continuance of the painful affection, 
treatment was more prolonged. Finally the tendency to 
a recurrence of the painful paroxysm was overcome. 
Three months have now elapsed since the last medication 
of the nerve, and there has been no return of the pain. 

A third case of sciatica in a man of fifty, who has 
been under my care for the past two months, and who 
has been treated in exactly the same manner as the 
two previous cases, exhibits every indication of even- 
tual complete recovery. 

These cases have aroused in my mind an interesting 
train of reflections, and I will take the liberty of stat- 
ing briefly some of the conclusions to which I have 
been unavoidably conducted : 

1. That this method of subjecting the nerve to the 
prolonged chemical action of an adjacent medicament 
possesses advantages of a theoretical and practical na- 
ture which are not easily over estimated. 

2. That this prolonged medication of the nerve, by 
incarceration of the medicament, is incomparably more 
advantageous than the ancient expedient of simple 
injection, without incarceration by suspension of the 
circulation. In the former case the medicament is 
held in contact with the nerve for a period of time, 
which may be prolonged at the discretion of the phy- 
sician. In the latter case it is a matter of extreme 
doubt whether the nerve is influenced to any appreci- 
able extent, since the medicinal solution is at once re- 
moved by the general circulation, and has, therefore, 
no time to induce the requisite chemical changes in 
the nerve filaments. 



lOG HEADACHE AND NEURALGIA. 

3. Solutions of low percentage {ifo or ifo) should be 
employed for prolonged medication of nerves, as it is 
thus possible to inject large quantities of the medica- 
ment without danger of constitutional symptoms. It 
is, moreover, clear that the prolonged presence of this 
large amount of fluid in the neigliborhood of the nerve - 
stem must inevitably, through the operation of imbibi- 
tion, profoundly affect the nervous filaments. 

4. The medicated fluid should be injected as near 
the affected nerve as possible ; but care should be ex- 
ercised not to wound the latter. These deep injections 
may be accomplished without pain by injecting a small 
quantity of the anaesthetic before the point of the 
needle, as the latter is propelled into the tissues. 

5. The treatment by prolonged medication is with- 
out danger, and therefore superior to nerve-stretching 
by the surgical method, whicli in point of rehability 
leaves much to be desired. 

6. Cocaine is only one of many fluids which may 
prove useful when applied according to this method. 

These, then, are some of the conclusions which have 
forced themselves upon me, and I confidently trust 
that the method of treatment above detailed may con- 
tinue to 3ield rich results in the hands of my colleagues 
in the profession. 

It would, of course, be possible to cite many cases of 
sciatica, in which, previous to perfecting local methods 
of treatment, I had resorted to such conventional re- 
sources as the actual cautery, the constant galvanic 
current, blisters and the like. The details of such 
cases are, however, at the present day of relatively 
little interest, and I therefore pass from this phase 
of the subject to the consideration of some of the 
varieties of face-pain. 

Both from the intensity of the suffering engendered, 



LOCAL MEDICATION OF NERVES, CONTINUED. 107 

as well as from the frc(iucncy of its occuiToiico, facial 
neuralgia is pregnant with intense practical interest to 
the physician. I trust, therefore, that a case or two 
illustrating some of the phases of the affection as well 
as some of the methods of treatment elaborated by 
myself may serve a useful purpose. 

V. C. E., a gentleman fifty -seven years of age, was 
referred to me by Dr. Cornelius R. Agnew, on account 
of severe supra orbital neuralgia. There is a distinct 
history of malaria, which the patient contracted at the 
South several years since. He was thoroughly treated 
with quinine at that time and was pronounced ''cured." 
Besides the supra-orbital pain, patient is frequently 
troubled by amblitory pains in the back and head, 
sometimes accompanied by flashes of heat, chills and 
feelings of malaise. All ordinary medication having 
been tried without avail, I put the patient under twenty- 
grain doses of antipyren three times a day in conjunc- 
tion with moderate bromization. In this way the 
general condition was much improved, and the pains 
about the head (supra-orbital and occipital) were for 
the time completely abolished. The supra-orbital pain 
returned, however, shortly after discontinuance of the 
remedies. On making a critical examination, a point 
of extreme tenderness was found in the course of the 
nerve ; and I therefore at once decided, the pati3nt 
readily consenting, to resort to local medication at this 
point. Having carefully marked the point of tender- 
ness with iodine, I proceeded to -cocainize the part, ad- 
justing the block and wire gauze as already described 
in the earlier part of this treatise. Before adjusting 
the gauze, however, I injected two drops of a solution 
of hydrocholoric acid of a considerable degree of con- 
centration into the zone of tenderness previously 
marked with the iodine stain. The block and gauze 



lOS HEADACHE AND NEURALGIA. 

were allowed to remain in place three quarters of an 
hour, at the end of which time they were removed, al- 
though the anaesthetic conditions still remained. Three 
minutes after the removal of the gauze the anaesthesia 
began to abate, and five minutes thereafter it had en- 
tirely disappeared. In its place there was a feeling 
of sli^'ht soreness ; but the characteristic shooting; 
pains had been entirely removed. There was also some 
swelling of the tissues at the seat of injection, as well 
as slight ecchymosis. These collateral features speed- 
ily disappeared (at the end of a week). For some time 
longer (three or foar weeks) the patient remained un- 
der my care, and although no medication other than 
general faradization was resorted to, there was not the 
slightest return of pain, nor have I since heard of any 
further discomfort, after the lapse of several months. 
Such a result as this speaks for itself; no more graphic 
illustration of the efficiency of the treatment adopted, 
where the pain is localized in a given nerve tract, could 
well be demanded. 

M. M. T., governess, referred to me by Dr. David 
Webster for supra- orbital neuralgia. About two years 
ago patient first began to experience pain above and 
around the left eye. Undue tension of the internal rec- 
tus muscle having been made out by the aid of prisms, 
Dr. Agnew decided to cut that muscle with a view 
to relieving the strain. After the operation there 
was, I believe, some relief for a time ; but the pain 
returning, she was referred to me by Dr. David Web- 
ster for further treatment. On examination, I found 
a well-marked point of sensitiveness in the course of 
the supra-orbital nerve. As the patient was averse 
to the injection of remedies, I tried all ordinary ex- 
pedients, such as galvanization, counter irritation and 



LOCAL MEDICATION OF NERVES, CONTINUED. '109 

internal remedies of various kinds, but witliout at- 
taining more than temporai'y results. 

Finally, by dint of some persuasion, I induced the 
patient to consent to the trial of local medication. Sen- 
sibility was abolished by the aid of the local anaesthetic, 
as in the cases previously described. An injection of 
TfVth of a grain of pyrogallic acid (pyrogalol) was then 
made into the painful spot, and the gauze and block 
applied for three quarters of an hour or more. 

On removing the gauze the usual gridiron appear- 
ance of the skin, caused by the pressure of the gauze, 
was present ; and shortly afterwards there was some 
swelling of the part, which, however, disappeared en- 
tirely in the course of a few days. The slight super- 
ficial soreness which almost always follows this plan 
of treatment also speedily subsided, and with this 
restoration there was a concurrent disappearance of 
every vestige of neuralgic pain. This exemption lasted 
until the famous " blizzard," when the patient having 
contracted a severe cold, there was some slight return 
of pain, not only in the supra -orbital region but in 
other parts of the face. This condition was, however, 
at once relieved by ten-grain doses of antipyren, which 
the patient was nevertheless obliged to discontinue 
on account of her extraordinary susceptibility to the 
remedy. In her case even five grains three times a 
day were sufficient to cause the characteristic rash. 

A tendency to persistency about the internal can- 
thus having been noted in this second painful attack, 
I decided to make an injection into the painful zone 
at this point. Although, in this instance, it was im- 
possible to apply the gauze effectively, I succeeded 
nevertheless in arresting the pain, as I trust perma- 
nently, there having been no complaint since. 

C. C. T.J a lady of sixty-three, came on from Green- 



110 HEADACHE AND NEURALGIA. 

field, Mass., to consult me for a severe form of tic dou- 
loureux, the pain being located in a circumscribed spot, 
about the size of a pea, at the posterior aspect of the 
upper alveolar process. She has no teeth in the upper 
jaw, and the gums are retracted and shrunken. Every 
known remedy having been exhausted, I endeavored 
to make injections into the painful spot, but at the 
first attempt the hypodermic needle was broken, in the 
endeavor to penetrate the hardened gums. A second 
attempt with a stronger needle resulted more fortu- 
nately, and I succeeded in depositing about ten minims 
of the fluid in the painful region. No relief whatever 
followed, however, owing to the fact that the medicinal 
fluid was not taken up by the hardened tissue. 

I next saw the patient in consultation with my dis- 
tinguished friend, the late Dr. Theodore E. Varick, 
and it was decided to loosen the gum by the aid of the 
elevator. This was accordingly done ; but the result, 
as before, was nil. Had the patient not been so ad- 
vanced in life, I should have advocated extirpation of 
the nerve, or at least its second branch ; but this, under 
the circumstances, was deemed hazardous, more par- 
ticularly as the patient was in a state of debility. 

There being no alternative, I put this good lady on 
whiskey, and insisted upon her taking it in sufficient 
quantities to deaden the painful paroxysms, of which 
she had from forty to fifty attacks a day. Later 
twenty-grain doses of antipyren four times a day were 
ordered, in conjunction with tonic treatment and the 
local application of steam to the gums. From these 
latter expedients she experienced considerable relief, 
but I was never able to wholly break up the attacks. 

This case is instructive as offering an illustration of 
a class of cases, in which I have been unable to apply 
the principle of local medication to mucli pmpose. 



T.OCAT. MEDICATION OF NERVES, CONTINUED. Ill 

I now desire to say a word concerning the endermic 
use of remedies in neuralgia, and more particularly of 
the application of pyrogalic acid and cocaine in this 
manner. 

It has long been known that chemical substances, 
particularly in solution, when brought in contact with 
raw surfaces are readily absorbed. Iodoform and car- 
bolic acid poisoning, as the sequence of too copious an 
appUcation of these substances about wounds, afford 
famihar illustration of the principle involved. Like- 
wise, when the skin is denuded of its epidermal shield, 
it becomes at once pervious to substances brought in 
contact with it. By perviousness of the skin is meant 
that the sub-epidermal vessels absorb those fluids 
which are brought immediately in contact with them. 
Upon the facts above detailed is founded what is known 
as *' endermic " medication, a procedure which enjoyed 
considerable popularity in the profession some years 
ago. So far as I am aware, cocaine has been used in 
this way to but a limited extent, and then only in a 
primitive fashion. Without claiming any great credit 
for originality, but guided rather by the desire to be 
of some slight use to those of my friends who may 
have occasion to resort to local anaesthesia for purely 
medical purposes, I will describe briefly the method 
of endermic ' administration which I have found most 
effective : I flrst remove the epidermis by the aid of 
vesicating collodion (Squibbs'). The denuded surface 
is then covered with an india-rubber membrane. The 
size of the membrane should be such that its edge 
projects somewhat beyond the raw surface. By the 
aid of a good adhesive preparation, the edges (see cut, 
C) of the membrane are securely glued to the sur- 

^ First desci-ibed by me in the "Journal of Surgery and Antisep- 
tics" for January, 1888. 



113 HEADACHE AND NEURALGIA. 

rounding unbroken skin. Should the adhesive mater- 
ial prove incapable of keeping the membrane in firm 
contact with the skin, a ring composed of thick wire 
may be placed upon the edges of the membrane and 
caused to exert firm pressure upon them by the aid of 
a band. As au additional precaution the edge of the 
membrane may be sealed with collodion. 

Through a metal nipple, provided with a screw- 
cap, and situated in the centre of the india-rubber, 
cocaine may be introduced beneath the membrane. I 
usually employ for the purpose an ordinary medicine 
dropper. Should there be pain in the part, as in neu- 
ralgia, it generally disappears in a relatively short 
space of time — in fact, as soon as a certain amount of 
the anaesthetic has been absorbed. 

The first case in which I had occasion to make trial 
of the above method was that of a woman who had 
long been the victim of neuralgic attacks. As a rule, 
the pain was most acutely felt about the temple, ex- 
tending backward toward the occiput, and this was 
the case when I saw her. By the aid of vesicating 
collodion, I removed the epidermis from her temple 
to the extent of a space about the size of a quarter of 
a dollar. Over this denuded portion of the skin I 
stretched the india-rubber membrane and secured it 
in place as above described. Fifty minims of a two- 
per-cent. solution of the hydrochlorate of cocaine were 
then placed beneath the membrane and the cap screwed 
do^vn. Ten minutes later the pain had begun to 
decrease, and twenty minutes thereafter had entirely 
disappeared. In spite of this favorable outcome, I 
nevertheless allowed the membrane to remain in place 
for the following three hours, replenishing the anaes- 
thetic through the metallic nipple every hour. During 
this time there was entire immunity from pain, and, 



LOCAL MEDICATION OF NERVES, CONTINUED. 



11: 



so far as one can perceive, a complete cure has been 
effected. But, even should there be a recurrence of 
pain at some future time, it would be a perfectly easy 
and proper expedient to repeat a procedure which 
has already yielded so good a result. In this connec- 
tion, I would observe that the greatest care should be 
exercised in securing the membrane to the skin, so 
that there shall be no leakage. A good india-rubber 
adhesive mass is the best substance which I have yet 
been able to obtain; but I am in hopes of finding 
something: still better in the course of time. 




Fig. 



The second case in which I tried this method, was 
one in which there was localized hypercesthesia of the 
fore-arm subsequent to hemiplegia. Throughout a 
district three and a half inches long by two in breadth, 
the epidermis was removed at regular intervals in 
pieces about the size of a pea; so that, after the com- 
pletion of the operation, the skin looked somewhat hke 
a sieve. Over this disti^ict the rubber membrane was 
stretched (see cut): and, being secured as before, the 
anaesthetic was introduced through the metal nipple 
(A) and the cap screwed on. The rubber blister {B) 
8 



114 HEADACHE AND NEURALGIA. 

was alloAved in this case to remain in place for two 
hours, during which time there was rehef from all 
hypera3sthetic symptoms. On the following day, as 
there was a return of the abnormal sensitiveness, I re- 
applied the membrane, being careful, however, to duly 
prepare the denuded surfaces beforehand,- as follows: 

TOILET OF THE DENUDED SURFACES. 

Since, after the lapse of several hours, there is an 
exudation of serum, followed by the formation of a 
firm network of fibrin, and since moreover this fibrin 
interferes greatly with the absorbent qualities of the 
bhstered surface, it is necessary to remove the same, if 
the denuded surface in question is to be further utili- 
zed. To this end, I am in the habit of introducing 
through the metal nipple a fine camel's -hair brush, 
saturated with a diluted solution of hydrochloric acid, 
to which a little pepsin has been added. By the ap- 
plication of this solution to the denuded surfaces, the 
fibrin is readily dissolved, the healing process broken 
up at its inception, and the denuded surfaces placed 
once more in a receptive condition. 

The second case just referred to is hardly a fair test 
of the permanency of the effects to be anticipated from 
this method of treatment, though it abundantly illus- 
trates the correctness of the principles underlying the 
procedure itself. 

The first case, on the contrary, affords a good illus- 
tration of what may reasonably be anticipated from 
this mode of treatment in certain phases of tic. 

I trust that, in giving a synopsis of the above cases, 
I have not trespassed too much upon the patience of 
the reader. To what has already been said, I desire 
merely to a-dd the statement that when the pains are 
diffuse in character, the painful points not well marked, 



LOCAL MEDICATION OF NERVES, CONTINUED. 115 

and in short the reflected pains lending a general 
character to the affection, antipyren is the remedy par 
excellence. As an adjunct of great value to all forms 
of local treatment it is also of the greatest possible ad- 
vantage; and the physician should have no hesitancy 
in thus resorting to it. 



PART III. 



HISTORICAL. 



CONSIDERATION OF METHODS OF TREAT- 
MENT HERETOFORE PROPOSED. 



CAPTTER XX. 

ELECTRICITY. 

It now remains to consider, in a general way, and 
from a more or less historical standj)oint, a number of 
remedies which from time to time have been advo- 
cated by various writers in the treatment of neuralgia. 
I would not for a moment, however, have the reader 
imagine that I myself am an advocate of all of this 
polypharmacy. From what has already been said it 
will readily be perceived that I entertain quite definite 
convictions as to the most philosophical method of 
treating this painful affection. 

At the same time I deem it but just to present a 
general survey of the principal points which have char- 
acterized the evolution of this branch of therapeutics. 
If the brief comments which I shall offer thereupon 
from time to time are often tinctured with ill-disguised 
pessimism, it is because I have so frequently seen many 
of these remedies fail utterly both in my own practice 
and in the hands of others. 

Among the more prominent remedies employed by 
modern physicians, none has given rise to more dis- 
cussion and conflicting testimony than Electricity. 
Both the galvanic, the induced and the static currents 
have been recommended. When the continuous gal- 
vanic current is employed the cathode is placed upon 
the sensitive points, while the anode is apphed as closely 
as possible to the centres (or upon the sternum, accord- 
ing to some authors). 



120 HEADACHE AND NEURALGIA. 

The faradic current is usually employed in conjunc- 
tion with the wire brush, the latter being directed 
along the course of the affected nerve-stems. As 
regards the relative value of the two currents prefer- 
ence is undoubtedly to be given to the galvanic, on 
account of its smaller tension. 

Where the cause of the disease is profoundly located 
in the central nervous system or in the nerve -roots, 
the galvanic current sometimes proves useful. Again, 
when a powerful ' ' catalytic ' ' effect upon nutrition is 
desired, the galvanic is to be preferred to the faradic 
current. As a matter of course, however, little per- 
manent good can be hoped for in those cases where 
the affection is due to coarse anatomical changes of the 
brain or cord. 

On the other hand, in the idiopathic varieties of 
neuralgia — those in which the pains are traceable to 
rheumatic or neuritic causes — the results obtainable 
from the employment of the galvanic current are oc- 
casionally good. Cures are, indeed, sometimes effected 
in a short time; but such cases are exceptional. 

The testimony of a large number of neurologists 
bears T^^tness to the value of electricity in certain 
phases of neuralgia; it cannot be said, however, that 
the therapeutic virtues of this remedy are displayed in 
all phases of the affection. 



CHAPTER XXL 

ELECTRICITY, CONTINUED. — SBIULTANEOUS APPLICATION 
OF PRESSURE AND GALVANISM. 

Of much greater value than the apphcation of gal- 
vanism alone is its employment in conjunction with 
a considerable degree of pressure upon the affected 
nerve filaments. In order to apply mechanical pres- 
sure, and at the same time pass the current through 
the aft'ected nerve-stem, I have had constructed the 
following simple device: 

A strong band of leather provided with an adjust- 
able buckle is transfixed by a screw, which is imbedded 
in an appropriately constructed metal garniture. One 
end of the screw is ovoid in shape and is covered with 
chamois skin, thus constituting a small electrode. To 
the other end of the screw is secured a tran verse cross- 
bar, which serves as a handle. This extremity of the 
screw is also provided with an appropriate mechanism 
for attaching the end of an ordinary conducting cord. 

In order to employ the apparatus, the strap is passed 
around the limb, in which the affected nerve is located, 
and secured by means of the buckle. The ovoid elec- 
trode is then placed over the most centrally located 
painful spot, and the screw is rotated until as much 
pressure is exercised as the patient can endure. In 
order to make this mode of treatment more comfort- 
able, I have recently resorted to the expedient of 
making superficial and deep injections of cocaine into 



122 HEADACHE AND NEURALGIA. 

the part before applying the pad; and I may add that 
I have found this a most useful expedient, especially 
in the treatment of sciatica. To continue the descrip- 
tion, the pad being properly adjusted, the disengaged 
end of the screw is then connected with the positive 
pole of an ordinary galvanic battery. An ordinary flat 
sponge electrode is then secured over some other por- 
tion of the continuity of the nerve or its branches by 
means of an elastic strap, and connected with the neg- 
ative pole of the battery. Having immersed the plates 
of the battery, the current is gradually increased until 
an intense burning sensation is produced. 

The first sitting should be brief in duration — from 
three to five minutes; but upon every subsequejit oc- 
casion the application should be prolonged. It is thus 
possible to progressively increase the duration of the 
applications, until finally from fifteen to twenty min- 
utes are endured. This, however, is only feasible in 
those cases in which the susceptibility of the nerve- 
stem to pressure and to the influences of the current 
becomes gradually less acute. Where the j^oiyits dou- 
loureux show an undue tendency to persist, only short 
applications of from three to five minutes at a time 
are as a rule possible.' 

For making prolonged applications about the cheeks, 
I employ a clamp electrode (Fig. IX), which, by the 
rotation of a screw embraces the cheek between two 
sponges (Fig. X). Each sponge is, of course, con- 
nected by a conducting cord with one of the poles of a 
galvanic battery. By a simple arrangement a consid- 
erably larger external sponge than the one seen in the 
cut may be adjusted. 

^ In old ctcses of sciatica and tic douloureux I have, however, 
on several occasions made applications lasting from half to three- 
quarters of an hour, and even longer, with excellent results. 



ELECTRICITY, CONTINUED. 



123 



I have also employed this appliance in the treatment 
of facial paralysis. ' 




»*aZflRQ.M»iBf"' 



Fig. 9. 



There can be no doubt that the electric current 
when thus employed, modifies the abnormal nutritive 




Fig. 10. 



conditions of nerves, allays persistent hyperaemic and 
inflammatory conditions, and thereby diminishes the 



» "The Medical Register," May 5th, 1888, page 413 et seq. 



124: HEADACHE AND NEURALGIA. 

excitability of the sensory nervous system. The pre- 
cise manner in which these beneficial changes are 
effected must, however, remain a mystery until ex- 
perimental pathology has done more for our enlighten- 
ment. 



CHAPTER XXII. 

NARCOTICS AND SEDATIVES. 

The second class of remedies, to which a prominent 
place must be assigned in the treatment of painful 
affections, constitutes the group of narcotics and anaes- 
thetics. Not a little of the success attending the em- 
ployment of these agents is attributable to the improved 
methods of administration, which have been introduced 
during the last few years. 

Foremost among the means at our disposal for allay- 
ing pain are opium and its alkaloids. The researches 
of Bernard have shown that opium depresses the irri- 
tability of the sympathetic system, and particularly 
that portion of it which supplies the submaxillary 
gland. The first effect of opium, especially when ad- 
ministered in small doses, is to increase the degree of 
irritability; but the primary effects soon give place to 
well-marked symptoms of depression. 

If large doses be given at once, the state of depres- 
sion is developed so rapidly, that the primary stage of 
irritability is evanescent in character or entirely un- 
recognizable. 

These facts afford a substantial basis upon which to 
found rational rules for the administration of the drug. 
When the nervous system is depressed, as in various 
exhaustive conditions of the brain and cord, the re- 
medy should be given in small doses, in order to obtain 
its stimulating effects; but when the irritability of the 
centres and peripheral apparatus is unduly increased, 



12G HEADACHE AND NEURALGIA. 

as in neuralgia and various other disorders, it should 
be given in large doses, in order to obtain the best 
results. There can be no reasonable doubt that much 
of the good obtainable from the use of narcotics in 
painful affections is attributable to the benefits arising 
from increased sleep, during which trophic and irrita- 
tive disturbances are corrected. This aspect of the 
question has, up to the present time, received far less 
attention than it deserves. 

The best manner of administering morphine, the al- 
kaloid of opium, which of late years has obtained such 
a high position among the resources of the j)harmaco- 
poeia,is by the means of the hypodermic syringe. When 
it is desired to exert a more or less general effect upon 
the nervous centres, the point at which the injection is 
made is not so much a matter of consequence as where 
a more local action is required. An}^ spot about the 
abdomen or arm, where the skin is at once thin and 
kose, and where there are few veins, will do. 

It is usually well to begin with a dose of from one- 
sixth to one quarter of a grain, and increase the same 
as required. When the effective dose has been ascer- 
tained, it may usually be employed for a considerable 
period without material increase. By degrees, how- 
ever, the system becomes habituated to the remedy, so 
that in the course of time it becomes imperatively 
necessar}^ to increase the dose in order to obtain the 
requisite physiological effects. 

It is well known to most physicians that the injec- 
tion of morphine about the head and neck may some- 
times be accompanied by transient sensations of 
faintness and anxiety, and even by confusion of ideas, 
sudden drowsiness simulating stupor and vomiting. 
These symptoms are usually devoid of any ominous sig- 
nificance, and since they soon pass off, no particular 



NARCOTICS AND SEDATIVES. 127 

measures for their removal need be adopted. More- 
over, if the patient has been previously apprised of the 
possibility of their occurrence, he is liable to experience 
no undue apprehension, and all danger from the effects 
of sudden fright are consequently removed. 

As a rule the injection is not required above once or 
twice a day, though where the pains are unusually 
severe the operation may be demanded oftener. Care 
should always be exercised to give the remedy as in- 
frequently and in as small doses as possible, with a 
view to obviating the dangers of the morphine habit. If 
we succeed in suppressing the paroxysms of pain for 
a number of days consecutively, the possibility of 
eventual cure is of course proportionately enhanced. 

A protracted use of large doses of morphine has the 
effect of thoroughly habituating the patient to the 
drug, so that the system not only thoroughly accommo- 
dates itself to the remedy but finally craves it as a 
physiological requisite. As a consequence of this state 
of things it is impossible to suddenly withdraw the 
drug from those long accustomed to its use, without 
producing a series of irritating and even dangerous 
symptoms. When thus deprived of the accustomed 
narcotic, such persons become weak, irritable and lose 
flesh rapidly, and if not sustained by copious stimula- 
tion they soon succumb. 

For my own part, I have had mach less occasion to 
resort to morphine or any other preparation of opium 
since I have made use of the methods of local medi- 
cation of the affected nerve-stems described at the be- 
ginning of the section on treatment. 

This ability of the physician to dispense in a measure 
with the aid of narcotics is not the least advantage 
offered by this mode of treatment. 

The other preparations of opium, such as codeine, 



128 HEADACHE AND NEURALGIA. 

narcotine, and narceine have not met with an exten- 
sive employment in neuralgic affections, and morphine 
must still be regarded as the most important alkaloid 
of the opium group. 

Of the remaining narcotics atropine, or belladonna, 
is worthy of special consideration, in connection with 
the therapeutics of neuralgia. The action of this drug 
is powerful, and it has been known to allay pain in 
cases where the administration of morphia has been 
entirely without result. Owing, however, to its ex- 
tremely poisonous nature, even when administered in 
small doses, it should be resorted to only in cases where 
other means have failed. 

Atropine is said to increase the irritability of the 
gray substance of the spinal cord, and its action upon 
the vaso-motor and respiratory centres is particularly 
pronounced. By stimulating the centre of the cardiac 
or accelatory nerve it acts as a powerful heart tonic, 
and Harley ' has recommended it in this connection. 

It has long been customary to employ narcotics in 
neuralgic affections in the form of various ointments; 
but of recent years the practice has been more or less 
neglected. An explanation for this is found in the 
difficulty experienced in causing these ointments to 
penetrate the stratum of epidermal cells. I have found 
that the efficacy of all such preparations is greatly en- 
hanced by removing the superior layer of dead epider- 
mial cells before applying the ointment. Moreover, 
I have observed that if the skin be in a state of more 
or less congestion, the efficacy of the ointment is cor- 
respondingly enhanced. 

Acting upon these two observations, I have elabo- 
rated the following method, to which I invariably 

' Harley on the Action and Uses of Belladonna, Braithwaite's 
Retrospect, Vol. LVII., 18G8. 



NARCOTICS AND SEDATIVES. 129 

resort where it is desirable to utilize the soothing prop- 
erties of narcotic ointments to the fullest extent. 
With a piece of ordinary window glass, the superficial 
strata of epidermal cells above the affected part, are 
carefully removed by scraping. A series of dry cups 
is then appHed, and allowed to remain in place until 
the entire cutaneous area of the affected locality is in 
a state of congestion. The skin being sufficiently 
livid, the cups are removed, and the ointment applied 
and thoroughly rubbed in with a piece of chamois 
skin. This procedure should be repeated, if necessary, 
several times each day. Narcotic plasters may be ap- 
plied in this manner, and allowed to remain in place 
for a considerable length of time, but, as a rule, they 
will be found to be less efficacious than the ointments 
frequently applied. 

The remedies best suited to be applied in the form 
of salves in neuralgic affections are veratrine, mor- 
phine, belladonna, aconitia and extract of opium. 

Aconitia (one part to thirty) should be rubbed into 
the painful areas until numbness is induced. 

Veratrine (one part to twenty-five) may be applied 
twice or thrice daily, care being taken to continue the 
frictions until pricking sensations are experienced. 
Erb recommends one part of belladonna, four parts of 
glycerine and four parts of starch, the ointment to be 
applied on a compress or rubbed into the painful cuta- 
neous districts. 

Where the paroxysms of pain are particularly 
violent and protracted, the employment of anaesthetics 
may be indicated. Chloroform and ether may be ad- 
ministered in the form of ointments, internally or by 
means of inhalation. As a rule, the latter method is 
to be preferred. The inhalations should not, however, 

be carried to such an extent as to produce profound 
9 



130 HEADACHE AND NEURALGIA. 

anaesthesia, but rather only to a sufficient degree to 
alleviate the intense pains. When thus administered 
they may be continued for almost indefinite periods, 
provided there is absence of cardiac or other organic 
affection. 

The chief objection to many general anaesthetics is 
the evanescent nature of their effects, which, when 
the inhalations are discontinued, soon pass off. It has 
been alleged that the paroxysms are much increased in 
violence after the employment of anaesthetics; but I 
can recall no instance of the kind within my own ex- 
perience. 

Hydrate of Chloral administered in large doses in- 
duces profound coma, but when given in moderate 
quantities it rapidily produces sleep. During the con- 
tinuance of its effects reflex action and sensation are 
more or less diminished, and death is caused by par- 
alysis of the heart or complete arrest of respiration. 
The effects of the remedy are in great measure due to 
its action upon the cerebral protoplasm, and not to 
any influence which it may be supposed to exert upon 
the intra-cranial circulation, I have had occasion to 
express my convictions upon this point on many pre- 
vious occasions, not only with respect to chloral, but 
also with regard to all anaesthetics. The action of 
chloral upon the sensory apparatus precedes its effects 
upon the central motor mechanism. This is perhaps 
owing to the greater facility with which endosmotic 
processes are accomplished among the sensory gan- 
glia. 

The degree of vascularity of an organ has also much 
to do with its amenability to narcotic influences. It 
will be readily understood that such must be the case, 
when it is borne in mind that the greater the volume 
of blood circulating in an organ, the greater wiU be the 



NARCOTICS AND SEDATIVES. 131 

amount of any narcotic conveyablo to that organ in a 
given length of time. 

However impotent chloral may be to allay pain in 
very severe cases of neuralgia, there is no denying the 
fact that its administration in many cases is followed by 
excellent results. These good effects are not attribut- 
able to any special anodyne influence of the remedy, but 
rather to its immediate and powerful hypnotic action. 
How important the element of sleep is in severe cases 
of neuralgia cannot fail to be appreciated by those Avho 
have marked the rapid deterioration that takes place 
in those suffering from the obstinate insomnia induced 
by severe and prolonged pain. While treating the 
painful paroxysms with every resource at our com- 
mand, care should be exercised to promote periodic 
sleep, since only thereby is it possible for the patient 
to counteract the devitalizing influences of severe and 
prolonged pain. 

Besides the remedies already discussed, a vast num- 
ber of other substances have been recommended in 
neuralgic affections from time to time. It would be a 
waste of time, however, to attempt to enumerate them 
aU, and I shall therefore content myself with referring 
to those of most importance. 

Bromide of Potassium is extremely valuable in those 
cases characterized by unusual irritability. It should 
be given during the day in moderate doses (10 grains), 
and supplemented, where there is pronounced insom- 
nia, by a small dose of chloral exhibited shortly before 
retiring. The tincture of hyoscyamus (in drachm 
doses) may be substituted for the chloral with ad- 
vantage in some cases. 



CHAPTER XXIII. 

OTHER REMEDIES WHICH HAVE BEEN RECOMMENDED IN 
THE TREATMENT OF NEURALGIA. 

Phosphorus has been given with good results in 
those cases of neuralgia characterized by a more or 
less exhausted condition of the central nervous 
system, or by general or local cerebral anaemia. The 
dose may be varied from one-fiftieth to one-twenty- 
fifth of a grain. 

Quinine has been recommended by a number of ex- 
cellent authorities, among others by Erb and Trous- 
seau. The former has found it of service when com- 
bined with small doses of morphine (quinine three 
grains, morphia one- sixth of a grain). 

Arsenic unquestionably occupies a high position 
among anti-neuralgic remedies. It may be given in 
the form of Fowler's solution in doses of from two 
to eight drops three or four times a day, the amount 
per diem being gradually increased. The hypodermic 
exhibition of the remedy possesses certain advantages, 
and may be resorted to in cases of stomachic trouble 
where the introduction of remedies per orem is contra- 
indicated. Arsenic possesses unusual efficacy in cases 
characterized by sanguineous impoverishment, as well 
as in those exhibiting marked symptoms of cerebral or 
medullary exhaustion or both. 

Iron in its various preparations, and particularly the 
chloride salt, is of no little value in treating those 
cases of neuralgia in which anaemia and a general 



OTHER REMEDIES FOR NEURALGIA. 138 

devitalized condition of the organism are prominent 
features. There is nothing, however, of a specific 
character in the action of any one of the numerous 
ferruginous preparations; only in so far as they affect 
the nutritive conditions of the organism at large are 
they to be recommended. 

Strychnia may be given hypodermically or in com- 
bination with the preparations of iron. I prefer the 
former method of administration. What has been said 
with regard to the various preparations of iron apphes 
in a general sense to the administration of strychnia. 
General anaemia or exhaustion of the vital resources 
of the brain or spinal cord are the primary indications 
for its administration. 

Zinc has been extensively recommended, and I have 
seen good results from its employment, especially when 
combined with the extract of hyoscyamus. Too much, 
however, should not be anticipated from the zinc prep- 
arations, on account of the uncertainty of the indica- 
tions for their administration. 

Valerianic an excellent general sedative to the 
nervous system, but is devoid of any well-marked 
narcotic effects. It has been recommended in various 
head-pains, hysteria, hypochondriasis, nervous irrita- 
bility and hkewise in the majority of neuralgias. I 
have seen the best results from its employment in 
those cases of neuralgia in which a strong hysterical 
element was present. 

VERATRIA, IODINE, CHLOROFORM, TURPENTINE, ETC. 

Embrocations of the above are often effective in the 
milder forms of the affection, but usually fail to afford 
relief in severe cases. On the other hand, the cerate 
of cantharides often proves efficacious where other 



13tl: HEADACHE AND NEURALGIA. 

vesicants have failed. There is nothing, however, of 
a specifically tonic influence in this, as some observers 
maintain, but the results are doubtless entirely attrib- 
utable to the derivative action of the remedy. 

As we have already had occasion to observe, the 
electric brush and moxa often transcend in efficacy the 
results obtainable by other derivatives; and since elec- 
tric apparatus has become so widely disseminated these 
methods of treatment may be employed by those who 
place faith in derivatives. 

Of late years the static electric current has been re- 
commended in the treatment of painful affections, and 
the results obtained in some cases of peripheral neural- 
gia are occasionally sufficiently striking. Dr. William 
J. Morton has done much towards investigating the 
therapeutic quahties of static electricity, and a perusal 
of his writings upon this subject will be found in- 
structive. 

I have already had occasion to refer to a method de- 
vised by myself for treating peripheral neuralgia by 
the application of a certain degree of pressure to the 
affected nerve-stem, Avhile at the same time the electric 
current is passed through the nerve at the point of 
pressure. The good results frequently obtainable by 
this mode of procedure are perhaps attributable in part 
to the powerful counter-stimulation: and probably not 
altogether to the temporary interruption of sensory 
conduction by pressure. 

What is true of the combination of galvanism with 
pressure applies in a limited sense to the application 
of pressure alone — a sufficiently ancient expedient, by 
the way. 

On the whole, however, not much of permanent 
good can be expected from the application of simple 
pressure alone; but on the other hand, I have seen 



OTHER REMEDIES FOR NEURALGIA. 135 

consitlerable and permanent benefit result from the 
systematic and persistent employment of galvano- 
l)rcssure, as described at the beginning of this chapter. 

Baths. — Baths hot and cold have long been em- 
ployed in neuralgic affections. As a rule hot baths 
will be found more serviceable than cold; this applies 
with particular force to those cases in which a rheu- 
matic element is discernible. On the other hand, 
tepid and moderately cold baths are sometimes of use 
in the neuralgias occurring in hysterical and neurotic 
women. In my own practice, I have come to regard 
the Turkish and Russian baths with special favor, 
particularly when combined with subsequent local mas- 
sage and frictions. Besides hot air and steam baths, 
various mineral waters have been employed in neu- 
ralgic affections with more or less success. Where 
the general system is greatly debilitated ferruginous 
waters may be given, and when combined with favor- 
able atmospheric conditions and appropriate diet they 
often prove valuable. 

Treatment by Freezing. — This is quite an old expe- 
dient, which has lately been revived by several physi- 
cians. I have not, however, been able to discover that 
these recent undertakings differ essentially from the 
exploits of the older writers. 

In common with other neurologists, I have at times 
had occasion to apply cold to the spine and peripheral 
nerves. Sometimes I have employed Chapman's ice- 
bag, at others I have resorted to ether spray. In 
either case it has always seemed to me that I was un- 
able to produce in full measure the benefit of the cold 
applications. This applies with special force to those 
cases in which I have attempted to treat neuralgia by 
local freezing. The poverty of effect sometimes wit- 
nessed in such cases I have been led to ascribe to the 



136 



HEADACHE AND NEURALGIA. 



antagonistic action of the local blood stream. By the 
antagonistic action of the blood, I mean the continual 
raising of the temperature occasioned by the uninter- 
rupted accession of warm blood to the part. 

To overcome this difficulty, I have resorted to the 
simple device shown in the figure. To the end of a 
curved handle, eight inches long, a ring, an inch and 
a half in diameter, is secured by an appropriate bifur- 




FlG. 11. 



cation. This ring serves as the frame of a dome of 
fine wire gauze, with its convexity directed downward. 
In employing the implement, the convex surface of 
the wire dome is pressed against that portion of the 
integument which it is desired to refrigerate (or anaes- 
thetize). The instrument is held with a full grasp of 
the hand, and considerable pressure should be exerted. 
If now a spray of ether, or, better, rhigolene is thrown 
upon the concave side of the gauze, anaesthesia may be 



OTHER REMEDIES FOR NEURALGIA. 137 

in luced in from a second and a half to three seconds. 
This rapid action of the spray is readily understood, if 
we bear in mind that the pressure of the gauze upon 
the part effectuall)^ occludes the vessels below it, parti- 
cularly the cutaneous capillaries. As a consequence, 
there being no warm blood stream to neutralize the 
(^fi^ect of the spray, its refrigerating action is given full 
play, not only on the skin, but on the subjacent parts 
as well. 

I have used this method of refrigeration, in conjunc- 
tion with previous injections of weak solutions of co- 
caine (of one or one-half per cent.), in neuralgia. Of 
course, the method is applicable to any part of the 
surface, notably about the head. For purposes of 
local anaesthesia or moderate refrigeration it is un- 
equalled. When it is employed for the latter purpose, 
it is usually well to resort to the ether spray, which 
should not be held too near the wire gauze, if we wish 
to avoid instantaneous congelation. When it is desired 
to make painless punctures with the hypodermic 
needle, the device will be found useful, as the anaes- 
thesia may be limited to a circumscribed spot of the 
integument. It is noteworthy that insensibility of the 
part may be perceptibly protracted so long as the ap- 
pliance is held in place. 

Sometimes I have preceded the refrigerating process 
by the injection in the vicinity of the painful nerve of 
two or three drops of ordinary distilled water. The 
effects obtainable from this mode of operating seemed 
to be quite equal to those observed after the injection 
of an anaesthetic. Ifc is evidently a question in these 
cases of a more or less permanent chemical effect com- 
bined with the mechanical element of freezing. 



CHAPTER XXIV. 

SURGICAL EXPEDIENTS. 

It noAv remains to note briefly certain operative pro- 
cedures, which have been resorted to by various sur- 
geons of eminence in desperate cases of neuralgia, 
where the ordinary methods of treatment have been 
without result. In this category belong the operations 
known as neurotomy and neurectomy. The first pro- 
cedure consists in simple divisio]i of the affected 
nerve J while in the second mode of operating a portion 
of the affected nerve is resected. Both these opera- 
tions are undertaken with the view of preventing the 
propagation of the painful sensations to the brain: 
but, since in neuralgias of centric origin benefit is 
sometimes obtained by resort to these operations, there 
can be no doubt that they exercise certain derivative 
influences in addition to their more immediate physi- 
ological effects upon conduction. 

The observation that interference with the circula 
tion in a neuralgic zone sometimes results in complete 
and permanent removal of the painful symptoms has 
induced surgeons to ligate the arteries supplying such 
districts. Thus Trousseau ' has divided and subse- 
quently compressed the temporal and occipital arteries 
in neuralgia of the head; and on several occasions the 
results so obtained are said to have been excellent. 
Actuated by similar motives an eminent surgeon of 

1 Cited by Erb. 



SURGICAL EXPEDIENTS. 139 

Germany/ ligated the carotid artery, some years since 
in a desperate case of facial neuralgia, with the hap- 
piest results, the cure effected being complete and 
permanent. Such heroic surgery requires shght com- 
mentary; it is self-evident that dangerous operations 
of this class should only be undertaken in cases of the 
most desperate character and after all other means of 
treatment have been exhausted. 

^ Nussbauiii. 



CHAPTER XXV. 

SOME CONCLUDING OBSERVATIONS ON RHEUMATIC, OSTEAL, 
AND PERIOSTEAL HEAD-PAINS. 

Eheumatic Headache. —This is probably little more 
than a modification of neuralgia, its prominent charac- 
teristics, tenderness of the scalp, aching of the teeth, 
gums and jaws, and its paroxysmal and hemi-cranial 
proclivities leading unavoidably to such a conclusion. 

There is complete absence, as a rule, of all disturb- 
ances of the cerebral circulation, or other evidence 
pointing to implication of the intra- cranial structures — 
facts v^hich are directly opposed to the idea entertained 
by some that the dura or pia are in some way con- 
cerned in the production of the morbid phenomena. 

Treatment. — Unquestionably the most potent means 
of combating this form of head -pain consists in the ap- 
plication of heat to the head. This is best accomplished 
by means of the water cap, (see Fig. III. at the be- 
ginning of this work), through the coils of which 
a current of hot water is allowed to circulate. In the 
absence of this ingenious apparatus, an india-rubber 
bag or even an ordinary wine bottle may be filled with 
hot water and applied over the painful points with 
good results. Should the pain prove severe and obsti 
nate in character, the injection of the fifth or even the 
eighth of a grain of morphine near the seat of pain wiU 
be found to render good service. 

What has already been said regarding the treatment 
of neuralgia in general, applies with equal force to 



CONCLUDING OBSERVATIONS ON HEAD-PAINS. 141 

many of these so-called cases of rheumatic headache. 
If the constitution exhihits signs of feebleness, appro- 
priate and regular exercise should be prescribed ; if 
there are evidences of general anaemia, iron, quinine, 
strychnine, milk, eggs, beef -tea, rare beef- steaks and 
good claret wine are indicated; and if the muscles are 
flabby and the sleep poor, the former condition shou!d 
be met with resort to daily massage, and the latter by 
the procurement by proper means of an appropriate 
amount of brain-rest. 

Osteal and Periosteal Headache. — This form of head- 
ache is due, as we have already had occasion to observe 
in connection with the subject of headache from disease, 
to secondary syphilis. This, at least, is true of the 
majority of cases. The treatment of such cases is 
largely a question of the administration of large doses 
of the iodide of potassium, to which small quantities of 
the bichloride of mercury may be added or not accord- 
ing to circumstances. Tonics and a special dietary 
may be prescribed where the general condition of the 
patient calls for such measures. 



PART IV. 



SPINAL IRRITATION. 



CHAPTER XXVI. 

SPINAL IRRITATION. 

As the affection known as spinal irritation represents 
a complex of symptoms which reveals its close connec- 
tion with neuralgic difficulties; and since, moreover, it 
is frequently found associated with various painful con- 
ditions of the peripheral nerves, it is necessary to a 
complete survey of our subject to consider this distress- 
ing difficulty somewhat more in detail. 

Let me begin, then, by stating that spinal irritation 
occurs with great frequency both among men and 
women. The diagnosis of the affection sometimes pre- 
sents difficulties, on account of its pr oneness to asso- 
ciate itself with other morbid conditions, such as 
neuralgia or hysteria. In typical cases, however, the 
symptoms observed are so characteristic, that they 
must undoubtedly be ascribed to a distinct pathological 
condition. 

Symptoms. — Like spinal exhaustion the affection 
develops gradually in the majority of cases. The first 
symptoms to appear are vague pains in the dorsal 
region along the course of the vertebral column. These 
pains are usually provoked by slight fatigue, such as 
that induced by walking or riding or even driving. 
Sometimes the subject complains in the beginning of 
dull burning sensations between the shoulder blades 
or at the base of the neck ; but whatever the character 
of the initiatory symptoms may be, the pains in the 
back soon become severe, and conjointly with their 



146 HEADACHE AND NEURALGIA. 

evolution there is usually a liigh degree of mental irri- 
tability. If at this time an examination be made, 
certain regions along the course of the vertebral column 
will be found extremely sensitive to pressure or tap- 
ping. A sponge saturated with hot water, passed along 
the spine, evokes painful sensations ; while the wire 
brush employed in conjunction with the faradic bat- 
tery often discloses painful spots, which pressure and 
the hot sponge may, perchance, fail to reveal. I regard 
an electrical test of the degree of relative sensitiveness 
as of great practical importance in this as well as all 
other forms of obscure spinal difficulty ; indeed, by the 
employment of this test, I have frequently succeeded 
in discovering localized areas of sensitiveness, which 
else had failed to reveal their presence altogether. 

I emphasize this point merely because I believe that 
far too much importance has been ascribed to the re- 
sults obtainable by digital pressure and percussion. 
In exquisite cases, however, the morbid sensitiveness 
is so obvious that delicate tests are superfluous. Under 
these circumstances the friction caused by the clothing 
is often intolerable, while the passage of the finger 
along the vertebral column reveals hyperaesthesia of 
the integument, which may be of great extent or 
limited to spots no larger than a small coin. Besides 
the condition of hyperaesthesia, various paraesthesia, 
such as burning sensations, formication, tingling and 
alternating feelings of hot and cold, are frequently met 
with. On the other hand, absolute paralysis and an- 
aesthesia are absent. Disturbances of motility, when 
they exist, merely consist in a lack of capacity for the 
performance of operations requiring endurance ; — the 
patient is soon weary, and even moderate use of the 
muscles is liable to provoke amblitory pains, which, 
though often intense in character, wander from one 



SPINAL IKKITATION. 147 

portion of the body to another in the most unaccount- 
able manner. Sometimes the subject complains of 
neuralgiform pains in the face and head, or in the 
upper or lower extremities ; but hardly have these sen- 
sations become established, when they gradually, and 
in some cases suddenly, disappear, only, however, to 
reappear in the form of vague, visceral, genital or 
vesical pains. These unstable pains are extremely 
characteristic, and often give rise to great discomfort 
and apprehension on the part of the patient, as well 
as confusion in the diagnosis. 

Local spasms are a frequent concomitant of irritable 
spine. Sometimes they assume the form of fibrillary 
twitchings, located in single muscles, whereas in 
another and larger class of cases spasms are widely 
distributed, involving entire groups of muscles. There 
is nothing of a violent or epileptoid character in these 
phenomena ; they are usually evanescent and disap- 
pear under the influence of appropriate treatment. It 
may readily be conceived that the location of the 
symptoms exhibited in each case will depend upon 
whether the functional disturbance is found at the 
superior, dorsal, or dorso-lumbar portion of the cord. 

Thus, if tenderness be found at the cervical portion 
of the cord, the subject is liable to exhibit vaso-motor 
disturbances manifesting themselves in sudden blush - 
iug and facial pallor upon slight provocation, or in an 
habitual frigidity of the extremities. Again, if there 
be hypersesthesia above the dorsal segments of the 
vertebral column, digestive and other disturbances are 
usually present ; while should the lumbar portions of 
the cord be functionally disturbed, vesical derange- 
ments, in the form of an increased and frequent desire 
to urinate give rise to the erroneous supposition that 
there is paralysis of the sphincter. Should the func- 



14S HEADACHE AND NEURALGIA. 

tioiial efficiency of the cord be more or less affected 
throughout its entire extent, the complex of symptoms 
is greatly amplified — there are palpitations, dyspepsia, 
spermatorrhoea, vaso-motor disturbances, fibrillary 
twitchings, sleeplessness and great psychical irrita- 
bility. Spinal irritation, though a functional affection, 
is sometimes exceedingly obstinate in character; and 
even when we succeed in abating or removing the 
symptoms, they are are prone to return. Neverthe- 
less, there is no doubt that, in the vast majority of 
cases, the disease is amenable to treatment, provided 
the therapeutic measures employed are appropriate, 
and at the same time rigidly adhered to, even after 
the symptoms have entirely disappeared. 

PatJiology. — The pathology of spinal irritation is not 
as satisfactory as might be desired, owing in part to 
the defective manner in which the few autopsies on 
record have been conducted, and in part to the extreme 
difficulty of obtaining post mortem examinations in 
this, as in other benignant nervous affections. Some 
writers entertain the behef that the symptoms are 
wholly attributable to hyperaemia of the cord, while 
other observers are equally convinced that anaemia is 
the true source of the phenomena. For my own part I 
am entirely of the opinion that the posterior columns, 
and more particularly those districts of the same, 
known as the posterior root zones, or columns of Bur- 
dach, are involved, and I can also conceive that the 
posterior horn is implicated; whether the circulatory 
condition present is one of hyperaemia or anaemia, I 
am by no means prepared to say with certaiiity. Of 
this, however, I am thoroughly persuaded, that the 
nervous elements themselves are in a state of abnormal 
irritability, whatever the condition of the circulation 
may be. And I beheve, moreover, that the question 



SPINAL IRRITATION. . liO 

of primary importance in treatment is the removal of 
such irritability by appropriate measures; and that 
having once accomplished this, we may confidently 
anticipate a corresponding amelioration in the vascular 
condition, be the same one of anasmia, hypersemia or 
alternate hypercemia and anaemia. ' My views in this 
resi)ect receive substantial support from the well- 
known relationship of the blood-stream to all active 
tissues. Further careful clinical and pathological ob- 
servations may perhaps serve to increase our knowl- 
edge respecting the intricate morphological questions 
involved. 

Diagnosis. — It is undeniable that spinal irritation is 
an affection often extremely difficult of accurate diag- 
nosis ; at least, this is true of the less typical cases. 
Where, however, the symptoms are well marked, less 
difficulty will be experienced in forming a correct con- 
clusion as to the true nature of the affection. 

The differentiation of spinal irritation from hysteria 
is, in a large number of cases, exceedingly difficult. 
This inability to differentiate the two conditions in 
certain cases does not, however, seriously interfere with 
the plan of treatment ; for, it is but reasonable to infer, 
that where the symptoms of two diseases are so inex- 
tricably blended, there must be a corresponding fusion 
of pathological causes. On the whole, therefore, the 
opinion that hysteria and spinal irritation, though 
separate affections, are frequently associated in one 
and the same individual, seems plausible. Where, 
however, the predominant symptoms of hysteria, gen- 
eral spasms, globus, and paralytic phenomena are found 
in conjunction with only minor indications of spinal 
irritation, the case should be adjudged one of hysteria. 

1 The possibility that we may have to do with these evanescent 
changes in the circulation has already been considered by various 
writers, 



150 HEADACHE AND NEURALGIA. 

From spinal exhaustion, the affection under consid- 
eration differs in this : that in the latter disorder, dis- 
turbances of sensibility predominate, whereas, in the 
former, marked diminution of the functional resources 
of the cord is the characteristic feature. 

Locomotor ataxia and myelitis, even in their earher 
stages, are not readily confounded with spinal irrita 
tion, since the lancinating pains, incoordination, and 
girdling sensations peculiar to ataxia are wanting ; 
and the same may be said of the anaesthesia, paralysis 
of the bladder and voluntary muscles of the limbs and 
contractures, Avhich are so characteristic of the latter 
affection. 

Spinal irritation is difficult to differentiate from 
Jiypercemia of the cord, except when the hypersemia is 
sufficiently intense to cause paralysis. It has been 
urged by a medical writer of distinction that '^ spinal 
irritation is made worse by the administration of ergot 
. . The reverse is true of strychnia, which, in all cases, 
aggravates the symptoms of myelitis, meningitis, or 
congestion, wliile it is an efficient means of cure in 
spinal irritation." My own experience does not accord 
entirely with the above; indeed, it has led me, in some 
cases, to a diametrically opposite conclusion . At this 
very moment, I have under my care a gentleman mani- 
festing all the appearances of spinal irritation, in whom 
the symptoms of the affection are greatly aggravated 
by strychnia in doses of one forty-eighth of a grain. 
This phenomena is readily explained if we admit that 
the sensory districts of the cord are in a state of ereth- 
ism. It is a matter of secondary importance whether 
this condition of irritability is accompanied by a hyper- 
aemic or anaemic stnte of tlie cord or not. 

' "A Treatise on the Diseases of the Nervous System." By Wil- 
liam A. Hammond. Page 47, seventh edition, 1881. 



* SPINAL IRRITATION. 151 

Meningeal tumors^ during their early stages, may 
doubtless give rise to symptoms closely resembling 
those induced by spinal irritation. But the disturb- 
ances produced by tumors are stable in character, and 
confine themselves with more or less strictness to cer- 
tain districts, v^hereas, the migratory character of the 
symptoms of spinal irritation constitutes a distinctive 
feature. 

On the vv^hole, therefore, where severe pain of an 
amblitory character exists in the spine, accompanied 
by great tenderness of the spinous processes, but with- 
out paralysis, anaesthesia, or other severe symptom 
pointing to grave organic trouble, it is safe to assume 
that we have to do with a case of spinal irritation. 

Treatment. — In the treatment of spinal irritation, 
the attention of the physician should be directed to 
those symptoms which owe their origin to the func- 
tional derangement of the cord, on the one hand, and 
to those manifestly attributable to a secondary condi- 
tion of cerebral erethism on the other. 

The removal of the local hyperaesthetic spots, though 
often a protracted operation, is usually attainable by 
the employment of a sufficient amount of patience, con- 
ioined with appropriate local measures. Among these 
have been recommended counter irritation by means 
of blisters, or the actual cautery. I cannot say I resort 
to these measures as much as formerly, for reasons 
which I vv^ill presently state. On the other hand, the 
application of the galvanic current to the spine, one 
electrode being placed two or three inches above the 
painful point, and the other an equal distance below 
it, will be found of service in many instances. The ap- 
plications should last from fifteen minutes to half ati 
hour, and should be undertaken at least once a day. 
General faradization also yields excellent results, espec- 



152 HEADACHE AND NEURALGIA. 

ially in cases of debility and anaemia. Of internal rem- 
edies, iron, quinine, and zinc will be found most useful, 
where the condition of the stomach will permit the 
employment of medicine. 

Neuralgic pains, stomachic difficulties, and other 
compHcations should be treated symptomatically in 
the order of their occurrence. We have already al- 
luded to the secondary condition of cerebral eretliism, 
manifesting itself in insomnia and extreme mental irri- 
tability. These latter symptoms exert an exceedingly 
prejudicial influence upoa the general health of the 
patient, and serve to sensibly diminish the prospects 
of a speedy recovery ; and they should, therefore, claim 
the particular attention of the attending physician. 
For an extended account of the measures to be 
adopted in the treatment of the various derange- 
ments of sleep, I would refer to the special chapter 
upon that subject at the end of this work, and also 
to my former publications.' As regards the irrita- 
bility, we would recommend the employment of the 
bromides, Mariani's coca wine, and, where there is no 
tendency to vaso-motor derangements (cerebral hyper - 
semia), stimulants may be administered in moderate 
quantities. And here, I would enter a protest against 
the extravagant and hysterical utterances of certain 
persons regarding what they conceive as dangerous 
attributes of the coca-preparations. In this matter, I 
agree with Hammond, that there is no foundation, 
whatever, for such apprehensiveuess. I usuall}" gi\^e 
brandy, whiskey, or rum ; or, where the stomach will 
bear it, Burgundy or Bordeaux, which may be taken 
at dinner. The administration of stimulants is, how- 

' " Brain Rest, being a Disquisition on the Curative Properties 
of Prolonged Sleep." By J. Leonard Corning, M. D. New York: 
G. P. Putnam's Sons, 1885. Second edition, page 36, et seq. 



SPINAL IRRITATION. 15)3 

ever, often impossible, owing to extreme suscepti- 
bility. 

After treating several cases, the physician inevitably 
becomes aware of the fact that in a certain proportion, 
his efforts do not meet with complete success; there is, 
in a word, an inordinate persistence of soreness and 
pain on pressure above the vertebrcB — a condition dis- 
couraging at once to physician and patient. In such 
cases, I have frequently resorted to local medication of 
the cord by means of deep injections between the ver- 
tebrae of the hydrochlorate of cocaine, in solutions of 
varying strength. The hypera3sthetic spots are those 
which I usually select for the injections, but I have 
no hesitancy in making from six to one dozen or more 
such injections along the course of the spine. Care 
should be exercised, in making these injections, to 
place the needle as near the ligamentum insterspino- 
sum as possible.' 

The results obtained by this plan of treatment are 
often astonishingly favorable; and it is a matter of 
surprise to me that in the face of the excellent effects 
obtained by local medication of nerves, literature con- 
tained nothing concerning the application of this prin- 
ciple previous to publication of my first paper. "^ I will 
merely add that in the Neiv York Medical Journal for 
November 6, 1SS6, I have described a painless method 
of anaesthetizing the skin which I believe is destined 
to prove an important aid in the treatment of hyper- 
aesthetic conditions of the nervous system. 

As the method of local medication here referred to 

^ For the benefit of those who are interested in the development 
of more potent methods of alTecting tlie cord in disease, I would 
refer to my article contained in the " New York Medical JournaF^ 
for October 31, 1885, and also to my monograph on " Local Antes- 
thesia." New York : D. Appleton & Co., 1886. 

* Op. cit. 



151 HEADACHE AND NEURALGIA. 

is destined, in my judgment, to render good service 
in these obstinate painf ijI conditions of the cord, I pro- 
pose to discuss the procedure at length, more particu- 
larly with a view to elucidating the technical points 
involved. I desire, also, to show by what simple means 
it is possible to deposit the medicinal substance in large 
quantity, in the immediate vicinity of the spinal cord, 
and yet avoid the slightest danger of wounding the 
latter. 

Some time ago, in an article published in the New 
York Medical Journal for October 31, 1885, I showed 
that when a given amount of a medicament is injected 
into the vicinity of the spinal cord certain modifications 
in the functions of the latter may be induced.' 

Thus, when strychnine is injected in this manner, 
the functions of the cord, and notably the reflexes, 
are greatly exalted; much more so, in fact, than if the 
medicament had. been simply injected into the general 
circulation, as in ordinary hypodermic medication. 
On the other hand, the modifications in function which 
I observed after injection of an anaesthetic, such as co- 
caine, were sensory in character — such, for example, as 
more or less complete anaesthesiae, tinghng, numbness, 
and various other paraesthesiae, these phenomena being 
principally confined to the parts below the point of in- 
jection. The line of argument which led up to these 
results it is not necessary for me to detail on this 
occasion; enough, that the experiments, which were at 
first conducted on dogs, were afterward verified in man 
and the expedient has since been resorted to on several 
occasions. I was careful, too, to point out that this 
principle of medication offered an admirable and here- 
tofore unsuspected and potent means of treating cer- 

'Read before the Medical Society of the State of New York, 
February 7, 1888. 



SPINAL IRRITATION. ' - 155 

tain derangements of the spinal cord. Thus, it was 
sliown that the painful phenomena which are present 
in spinal irritation may be combated by resort to this 
exceedingly direct and effective therapeutic procedure ; 
and to this I may add that the permanency of the 
effects produced are enhanced by the combination of 
cocaine with other remedies. 

Having ascertained this much, it occurred to me 
that it would be a matter of practical interest to pursue 
these researches further ; accordingly, shortly after 
the publication of the paper above referred to, I con- 
ducted the following experiments :' 

1. I injected a solution of sulphate of strychnine 
under the skin of a rabbit in sufficient quantity to 
induce general convulsions. I then injected a quarter 
of a grain of hydrochlorate of cocaine subcutaneously, 
but without modifying in the shghtest degree the con- 
vulsive phenomena; in a word, I may state that I con- 
tinued to inject this drug (hydrochlorate of cocaine) 
initil well-marked toxic symptoms had been developed, 
but was not successful in modifying the convulsions 
to the slightest extent. The results thus obtained are 
directly at variance with those recorded by certain 
recent German observers. 

2. In this experiment I again induced the convul- 
sions by subcutaneous injections of the sulphate of 
strychnine, but instead of injecting the cocaine under 
the skin of the animal, I injected ten minims of the 
four-per- cent, solution between the spinous processes of 
the vertehrce. The first injection was not followed 
by any marked reduction in the tetanic sj^mptoms for 
several minutes ; therefore, at the end of ten minutes 

^ See in "The Medical Record" for March 17th, 1888, an article 
entitled : "A Further Contribution on Local Medication of the 
Spinal Cord, with Cases," by J. Leonard Corning-, M.D. 



156 HEADACHE AND NEURALGIA. 

I injected the same quantity as before, except that it 
was distributed in several inter-vertebral spaces. After 
the lapse of about fifteen minutes from the first injec- 
tion the severity of the convulsions had markedly 
decreased, and the animal could be handled without 
their induction. 

From the first experiment, therefore, it is clear that 
the injection of cocaine preparations into the general 
circulation, even in large quantities, is not sufficient 
to counteract the toxic effects of strychnine. Experi- 
ment shows, on the other hand, that when the drug is 
brought in a concentrated form into the immediate 
vicinity of the cord the reflex phenomena may be 
markedly diminished, provided, of course, that a too 
large quantity of strychnine has not been taken. 
When we consider how much greater the local than 
the general action of the drug is, this disparity of effect 
is easily accounted for. But it is in the painful affec- 
tions of the cord, such as ataxia, that I believe we shall 
attain notable results by resorting to this direct method 
of medication. So convinced have I become of the 
necessity of making some radical departure in our 
mode of attacking these painful maladies, that when 
I had observed the phenomena recorded in my first 
paper,' I resolved, as soon as an opportunity should 
present, to test this local medication in the painful 
affections of the cord. There was one obstacle to the 
execution of these plans, however, which puzzled me 
for a long time. Briefly stated, the problem in ques- 
tion is this: How is the physician to know how far 
he may thrust the hollow needle, used in transmitting 
the medicament from the syringe to the vicinity of 
the cord, without danger of wounding the latter ? 

' "Spinal Anaesthesia and Local Medication of the Cord," the 
"New York Medical Journal," October 31,1885; see also "Local 
Anaesthesia," D. Appleton & Co. 



SPINAL IRRITATION. I . 157 

As I have said, this problem puzzled me for a long 
time ; and yet there was no evading it, for I saw at 
once that if the procedure were to prove effective it 
could only be by depositing the medicinal substance as 
close to the cord as x)ossible. There are not many prob- 
lems in this life, however, which cannot be solved by 
hard and properly directed thinking, and this one 
proved no exception to the rule. To make a long story 
short, I succeeded completely ; and this is how the 
matter was accomplished. Having examined the ver- 
tebra of the lower portion of the spinal column, I ob- 
sei'ved that the posterior surface of the transverse 
process, even at its greatest depression, though almost 
on a level with the posterior aspect of the foramen 
vertebrae, did not fall at all, or, in rare cases, possibly 
very slightly below it. This is especially true of the 
ninth, tenth, eleventh, and twelfth dorsal, and of the 
first and second lumbar vertebrae. As soon as I had 
observed this anatomical coincidence, I saw at once 
that, in so far as the lower vertebrae were concerned, 
the problem of approaching the immediate vicinity of 
the cord with the point of a hypodermic needle, without 
danger of wounding it, was solved. In a word, to make 
the matter short, the simple technique which I elabor- 
ated on the basis of these observations is as follows : 

1. I first, as a rule, induce a condition of cutaneous 
anaesthesia in the vicinity of the spinous processes of 
the tenth and eleventh dorsal vertebrae almost as large 
as a silver dollar. This I do simply for the comfort of 
the patient and for no other purpose. The electro- 
chemical method ' elaborated by me, or the hypodermic 
syringe, may be employed for the purpose. 

2. I now call into requisition a fine needle, about 
three inches long, provided with a handle and a shding 

^ See the " New York Medical Journal " for November 6, 1886. 



158 



HEADACHE AND NEURALGIA. 



nut (Fig. XII). The latter may be fixed at any portion 
of the continuity of the needle by means of the screw. 
This needle I thrust down (about half an inch laterally 



Fig. 12.— Exploratory Needle. 



from the spinous process of the tenth dorsal vertebrae) 
until the bone is reached. The nut is then pushed 
down tiU it rests lightly upon the skin, (Fig. XIII) and 




Fig. 13. —Showing SIanner of Employing the Exploratory Needle. 

is secured in place by means of the screw. I then 
withdraw the needle. 
It is now clear, from what has already been said, 



SPINAL IRRITATION. 



150 



that the distance from the nut to the point of the 
needle corresponds almost exactly witli the distance 
from the surface of the integument to the cord. To 
make assurance doubly sure, however, I am in the 
habit of subtracting two or three millimetres from the 
measurement thus attained 




Fig 



Hollow Needle and Sliding Nut. 



3. Upon a fine cannula (Fig. XIV), likewise provided 
with a sliding nut, the distance previously noted upon 
the needle is measured off (minus, two or three milli- 
metres), and the nut secured firmly in place. 

4. This hollow needle is then attached to a syringe 
(Fig. XV) of one hundred minims capacity, filled with a 




Fig. 15.— Syringe of One Htodred Minims Capacity. 

one-and-a-half -per-cent. solution of the hydrochlorate 
of cocaine, to which is added about gr. -^-^ of pyrogal- 
lic acid. I have used solutions of various strengths, 
but am inclined to give preference to those of one-and- 
a-half per cent. 

5. The camiula is now thrust into the tissue between 
the spinous processes of the tenth and eleventh dorsal 
vertebrae (I have sometimes inserted it between the 



IGO HEADACHE AND NEURALGIA. 

ninth and tenth), until the nut, previously firmly fixed 
as described, rests upon the integument.' The con- 
tents of the syringe are now slowly emptied, and the 
needle withdrawn. 

0. The patient should now be allowed to lie on his 
abdomen, with his legs hanging over the edge of the 
sofa or bed in such wise as to put the dorsal muscles 
on the stretch. This manoeuvre presses the fluid in 
the direction of the least resistance, i.e. the cord, be 
sides causing the rigid muscles to act, in a certain sense, 
as an incarcerating mechanism; that is to say, that, in 
their rigid condition, they prevent the medicament, to 
some extent, from being absorbed by the tissues out- 
side of the spinal canal. Of course, when the solution 
has once entered the spinal canal, we can do nothing 
to keep it in permanent contact with the cord. The 
circulation at the lower segmeats of the cord is, how- 
ever, as is well known, extremely lethargic, so that 
the solution cannot be washed away very rapidly. 
This torpid state of the circulation, already alluded to 
by Brown-Sequard in his papers on paraplegia, no 
doubt accounts for the persistence of numbness and 
anaesthesia more or less profound after the injections 
have been made. 

So much, then, for the technique of this mode of 
treatment. Eelatively long as is necessarily the de- 
scription, the execution of the manipulations them- 
selves is by no means so difficult as might be imagined. 
I have employed the procedure many times, sometimes 
using cocaine alone, and sometimes combined with the 
tincture of aconite or pyrogallic acid, according to the 
effects which it is desired to obtain. 

' AVhen the injections are made in the upper and middle dorsal 
regions the precautions detailed above are not so necessary, 
though, perhaps, on the whole, they are preferable. 



SPINAL IKKITATION. 101 

In the affection commonly known as spinal irritation, 
whether there be a condition of congestion or ancemia 
I care not, its effects are certainly in the highest degree 
beneficial, as I have already had occasion to demon- 
strate to my entire satisfaction in several cases. How 
much may be obtained in inflammatory affections of 
the cord only an extended experience can, of course, 
determine. In purely functional derangements, how- 
ever, its efficacy is beyond question. 

The following brief synopsis of cases will serve to 
exliibit the promptness and permanency of the effects 
often obtainable by resort to this mode of treatment. 

1. Mrs. C , a young married lady, consulted me 

some months since on account of severe pains between 
the shoulders and at the back of the neck. These 
pains were exceedingly persistent. They were readily 
evoked by slight exertion, such as bending forward, 
walking, or lifting small objects, and they had failed 
to yield to any sort of treatment whatsoever. Previous 
to consulting me, this good lady had submitted to an 
ordeal in the way of treatment which was as unique 
as it was ineffectual. Her back had been cauterized 
repeatedly ; she had been plied with all manner of 
drugs, so that her stomach was in an exceedingly bad 
condition ; and last, but not least, her vagina had been 
bedouched, besalved, and bestuffed, according to the 
most exacting tenets of modern uteromania. It was 
natural, in the face of all this, that the mind of the 
patient should have become somewhat hypochondria- 
cal ; and it was equally to be anticipated that her 
morbid reflections would centre upon the pelvic organs ; 
so that when, during the consultation, she asked me, 
with considerable trepidation, whether I did not believe 
that she '^ had better have her womb cut out to cure the 
pain in her back," I was not inordinately astonished. 
6 



162 HEADACHE AND NEURALGIA. 

An examination of the spine revealed three exceed- 
ingly tender points at the upper and middle dorsal re- 
gion. At two of these points pain was at once induced 
by pressure, at the third spot it could only be evoked 
by the application of the electric brush. 

Such being about the condition of affairs, I decided, 
with the patient's full concurrence, to try the effect 
of local medication at the seat of pain. 

Having filled the large glass syringe already referred 
to with a solution containing gr. J- of pyrogallic acid 
and one-and-a-half grain of cocaine to one hundred 
minims of water, I injected the entire contents of the 
syringe (one hundred minims) into the upper painful 
spot. Ten minutes later there was no pain at the 
point of injection ; and what, at the time, seemed still 
more remarkable to me, the tenderness had entirely 
disappeared from the painful spots below the point of 
injection. As I now look at it, I am inclined to ascribe 
this striking phenomenon to the gradual deportation of 
the anaesthetic into the regions below the point of in- 
troduction. This explanation would seem to accord 
well with what we know of the distribution of the 
blood-vessels in the spinal canal ; but I will not incur 
the danger of wearying the reader by further specu- 
lations on this point. 

Enough that after this single injection the patient 
was able to execute all kinds of movements, such as 
bending forward, lifting objects from the floor, and 
the hke, without the slightest pahi. This exemption 
from suffering continued during the eleven following 
days, when having, as she thought, exposed herself to 
the effects of cold while riding in a horse-car, there 
was a return of severe pain. I again made an injection 
as before, selecting for the purpose the region about 
the second painful spot. A like happy issue was the 



SPINAL IRRITATION. 163 

result, complete abolition of pain, an exemption which 
has continued, so far as I know, up to date. 

2. Neurotic youth of sixteen. Has been addicted to 
masturbation for some years, a habit which he says 
he acquired at school. His parents, however, insist 
that he was addicted to the practice before going to 
school. That as it may be, there is pretty good evi- 
dence that he has masturbated more or less since his 
tenth year. 

Six months ago I was consulted by the parents of 
the boy on account of a severe pain located at the 
lower portion of the back. On examination tender- 
ness on pressure was found at the eighth dorsal and 
tenth lumbar vertebrae. When the patient attempted 
to bend forward the pain evoked was quite acute. Of 
late he has been able to indulge in walking but little, 
owing to the painful sensations to which it, as well as 
all forms of exercise, gives rise. Is sleepless, irritable, 
and depressed. 

Most of the conventional remedies haAang been tried 
without avail in his case, I determined, his parents 
readily consenting, to try the efficacy of local medica- 
tion. Accordingly, I injected seventy-five minims of 
an aqueous solution containing gr. ^V of pyrogallic 
acid, and gr. li of cocaine at each point of tenderness. 

In ten minutes the patient could execute all kinds 
of bodily contortions, such as bending forward, later- 
ally, and even backward. 

The relief lasted for hours, and, indeed, for the next 
four days there was marked improvement. At the 
end of that time, however, the local tenderness again 
appearing, if anything, in a more aggravated form 
than at first, I again made the injections precisely as 
before, and with the same results, except that the 
effects were altogether more permanent, lasting for 



164: HEADACHE AND NEURALGIA. 

the following three or four weeks. A slight degree of 
tenderness then made its appearance, and, strange to 
relate, at a point higher up. An injection was at once 
made at the painful point, resulting, as usual, in com- 
plete abolition of all tenderness. Several months hav- 
ing now elapsed and no complaint having been made, 
except on accouut of occasional cutaneous hyperaes- 
thesia, which is as usual relieved bj a strip of ordinary 
belladonna plaster, I think that we are perhaps justi- 
fied in looking upon the case as practically cured. 

3. A young man, twenty -two years of age, was re- 
ferred to me some time since by Dr. L. Bolton Bangs. 
Briefly, the patient had been operated upon for stric- 
ture by Dr. Bangs, and six days afterward developed 
severe spinal irritation. 

]\Iore or less dull pain was felt in the lumbar region 
and sacrum, extending to the lower dorsal vertebrae. 
At the seventh dorsal vertebra pain on pressure was 
exceedingly acute ; and from this point intercostal 
pains of great intensity, particularly on the left side, 
were radiated, so that breathing was shallow and ac- 
companied by much distress. 

Dr. Bangs had recourse to large doses of ergot, and 
applied the actual cautery to the back of the patient 
in a most thorough manner. Still, though there was 
apparently some amelioration, it was felt that the relief 
experienced was far from satisfactory. 

Accordingly, Dr. Bangs, being cognizant of my in- 
terest in local medication of the cord, requested me to as- 
certain whether the severe pains, ajid particularly those 
about the chest, could not be relieved by local means. 

Appreciating the necessity of affording as speedy 
relief as possible, I at once injected one hundred min- 
ims of an aqueous solution containing about one-six- 
tieth of a grain of pyrogallic acid, and one grain of 



SPINAL IRRITATION. , 105 

cocaine, luto the painful zone in the immediate vicinity 
of the seventh dorsal vertebra. 

Ten minutes after the injection had been made, the 
patient exi)erienced complete relief from the intercostal 
pains. He could bend the body from right to left, 
backward and forward, and inflate his lungs to their 
fullest capacity without the semblance of pain. Pres- 
sure upon the seventh dorsal vertebra also failed to 
evoke the shghtest sensation of discomfort. During 
the following two hours patient remained in my office, 
and at the end of that time, there being no sign of re- 
turning discomfort, I allowed him to walk home un- 
attended. Three days later he again reported at my 
office, and, though an examination of his spine re- 
vealed some superficial soreness, the deep-seated pains 
were not evoked, nor had there been any return of the 
intercostal pains. For the relief of the cutaneous 
soreness the simple application of a strip of belladonna 
plaster was found sufficient. 

The subsequent course of the case presents some 
interesting genito-urinary features, which I trust at 
some future date Dr. Bangs will elucidate with his ac- 
customed skill. As for the spinal irritation, I feel that 
a cure has been practically effected, although the severe 
changes in temperature experienced during the last 
few weeks have evoked at times a slight return of 
soreness. This soreness has been easily controlled by 
moderate doses of antipyrine. 

Several weeks after the above was published, patient 
called upon me and informed me that he had long 
since discontinued the antipyren, as the pain had 
entirely left him. 

4. Old case of spinal concussion in a gentleman of 
fifty, who met with a railway accident some years 
ago. Has been under my care for many months, and, 



166 HEADACHE AND NEURALGIA. 

although ahle to dispel the psychical depression from 
which he has long been a sufferer, I was, until re- 
cently, unable to abate a severe soreness at the region 
of the lower dorsal vertebne. This soreness he as- 
cribes to the fact that he was caught between two 
seats of the car on the occasion of the railway accident 
above referred to. 

Having tried all the usual superficial local measures 
without success, I undertook, with the patient's con- 
sent, to abate the symptoms by resort to deep local 
medication. As in the previous cases, the injections 
were conducted at the seat of pain, with every precau- 
tion, and with the result of affording complete and im- 
mediate relief from the painful symptoms. Four days 
after the injections there was some slight return of 
soreness, but this was at once controlled by supple- 
]nentary injections. Some weeks have now elapsed 
sin(^e the last injection was made and there has been 
no return of pain. 

5. N. I., a young lady of twenty-three years of age, 
was brought to me in consultation by Dr. Simpson, a 
prominent practitioner of Massachusetts. 

The following notes of her case are compiled in part 
from Dr. Simpson's letters and in part from my own 
case book. Her general health is good, appetite fair. 
She is well nourished, but has suffered, for the past 
five years, from severe pain in the head and back. On 
examining the spine several points of great tenderness 
were discovered. One of these is located at the lower 
cervical, one at the middle dorsal, and one at the lower 
portion of the lumbar region. Till within a compara- 
tively recent period, patient has exhibited no hysterical 
symptoms ; of late, however, she has been troubled by 
occasional attacks, which are evidently of an hyster- 
ical nature. At times is irritable and depressed, and 



SPINAL IRRITATION. ^ 107 

at all times she exhibits much susceptibility to sensory 
iini)ressions, and particularly to noises of all kinds. 
Thus, while I was conversing with her, she requested 
me to arrest the pulsations of a faradic battery, which, 
she said, caused her great annoyance. Dr. Simpson 
writes me that the rumbling of a cart or the sound of 
hammering are quite unendurable to her. ^ ^ Medication 
has done little for her, electricity has done nothing." 

She has had a good deal of cervical erosion, which 
has yielded well to the measures employed by Dr. 
Simpson. In spite of these local benefits, there has, 
nevertheless, been no diminution in the severity of 
the dorsal pains. Menstruation is regular, but occa- 
sionally accompanied by some pain. Motions of the 
body, such as bending forwards or backwards or to- 
wards the side, evoke the dorsal pain or increase it. 
The same is true of riding in a carriage. 

This was substantially the condition of the patient 
when Dr. Simpson brought her to my office on the 
fifth of April, 1888. 

After consultation, it was decided, inasmuch as all 
other remedies had failed, to resort to local medication 
of the cord. 

The point selected for the first injection was the 
point of tenderness in the lower lumbar region. 

A careful preliminary measurement to the trans- 
verse process having been made, one hundred minims 
of a 1 ^ solution of cocaine were injected into the pain- 
ful region. As I was careful to thoroughly refrigerate 
the painful area with the rhigolene spray before mak- 
ing the injection, the pain caused by the puncture 
was insignificant. Shortly after the conclusion of the 
operation, the patient manifested great nervous excite- 
ment, and complained of sensations of tingling and 



IGS HEADACHE AND NEURALGIA. 

numbness in the hands and feet. There were no 
motor disturbances whatever. 

This condition of exaltation lasted an hour and a 
half, when the patient was able to enter her carriage 
and be driven to the hotel. 

On the following day I saw her for a few moments, 
and though complaining of slight cutaneous soreness, 
she declared that deep-seated pain had entirely disap- 
peared in the lumbar region. 

I have cited this case as affording a fair illustration 
of the persistent tendency of the analgesia evoked by 
this application of the drug. My case book contains 
the records of many other cases in which I have re- 
sorted to this mode of treatment. At some future 
time it is my intention fco pubhsh a tabular report of 
these cases. 



CHAPTER XXVII. 

SPINAL IRRITATION AND OTHER PAINFUL SYMPTOMS 
CONSEQUENT UPON SLIGHT LOCAL INJURY OR GEN- 
ERAL SHOCK. 

To my mind no history of spinal irritation can be 
regarded as complete that does not include a descrip- 
tion of that interesting group of symptoms which su- 
pervenes as the result either of slight local traumatism 
or as the sequence of a severe shake or shock. These 
are the cases so admirably described in the foiu'th 
and fifth chapters of Erichsen's classical work on 
*' Concussion of the Spine ^' — a book the importance of 
which as a practical contribution to the pathology of 
the cord is not easily overestimated. Few scientific 
books have given rise to more criticism than this ; few 
have been more condemned, few more applauded. To 
state these facts is but another mode of proclaiming 
the epoch-making qualities of this admirable little 
volume. For my own part, I must confess to but one 
emotion after the perusal of each successive edition of 
this admirable contribution to neurological literature — 
that of profound admiration — a sentiment of such 
proportions, withal, that in its presence the merest 
thought of criticism would have seemed an act of sac- 
rilege. 

It is in this spirit of full acceptance, then, that I 
now propose to consider that particular phase of spinal 
concussion which makes its appearance soon or it 
may be a long time after general shock or shght local 



170 HEADACHE AND NEURALGIA. 

injury. In order to contribute to a greater fullness 
and understanding of the subject, I shall cite cases 
from my owu practice as well as some of the more 
graphic histories recorded by Mr. Erichsen. 

Symptoms —If a man be suddenly precipitated from 
an elevation, and strike with violence upon the back, 
or if he be caught between two seats of a railway car 
in the course of an accident, so as to bruise, say the lum- 
bar portion of his spine, a train of grave symptoms 
may be developed, pointing to profound derangement 
of the functions of the cord. There may be immediate 
paraplegia, or some other phase of paralysis; there may 
be retention of urine; there may be various forms of 
parsesthesiae — formication, numbness or even total 
anaesthesia of the affected parts ; or, paralysis ac- 
companied by one or more of these phenomena. 
Sometimes, after some febrile disturbance, of short 
duration, the symptoms begin to abate, and eventual 
complete recovery takes place. Sometimes, however, 
the termination is not so favorable ; there is more or 
less persistence of dorsal pain, with numbness or sen- 
sations of pins and needles, accompanied by depression, 
derangements of memory and other symptoms point- 
ing to profound implication of the cerebro-spinal sys • 
tem. The spinal tenderness present in such cases is 
often of an exquisite and obstinate character— all the 
resources of counter-irritation and internal medication 
being usually exhausted without appreciable ameliora- 
tion. Of late, I must confess, however, that I have 
experienced far less difficulty than formerly in control- 
ling this local irritation. I shall take occasion to return 
to this point jDresently. 

If, in addition to direct concussion of the spine, a 
blow upon the head has also been received, it not in- 
frequently happens that in the course of time epilep- 



smnaL irritation. ITl 

tiform seizures are added to the cord symptoms, the 
clinical history being somewhat changed, and the i)rog- 
nosis thereby nmch clouded. Finally, the blow upon 
the spine may be but slight or altogether absent, the 
subject being merely thrown violently about as in cer- 
tain railway accidents. Under these circumstances, 
the symptoms are often slowly evolved, and though 
frequently less severe than when the sequence of a 
direct and violent traumatism, they nevertheless par- 
take of an insidious and lethargic character, which 
puts the patience of both client and physician to a 
severe test. 

Accidents of this class have now become so common, 
in consequence of the manifold complications of modern 
society, that attention to this branch of pathology will 
amply repay the practitioner for any additional trouble 
which a proper familiarization with the subjects may 
entail. As already noted, the painful localities along 
the spine, so constant a feature of such cases, are emi- 
nently worthy of the attention of the practitioner who 
aspires not only to a scientific diagnosis, but to effective 
therapeutics as well. 

At this portion of the discussion, I believe that I 
cannot do better than cite a case or two from my own 
practice, as well as from the ample experience of Mr. 
Erichsen. 

H. C, merchant, aged 52 years, of strong, muscu- 
lar constitution, consulted me in February, 1884, for a 
train of severe nervous symptoms, which caused great 
anxiety both to himself and family. 

The following are the more prominent points in the 
history of the case: 

One year previous to consulting me, he had the mis- 
foi'tune to travel on a railway train which met with 
a serious accident. The accident in question, as it 



172 HEABACHE AND NEURALGIA. 

afterwards appeared, was caused by the spreading of 
the rails immediately in front of a long trestle-work. 
Several of the coaches were thrown from the trestle 
into the water, many of the occupants being caught 
between the seats or thrown about and severely injured. 
Others, again, were caught beneath the flying debris 
and drowned, while yet others succeeded in making 
their escape from the windows of the coach. Among 
the latter was a distinguished officer of the United 
States Army and the gentleman with whose history 
we are now concerned. Had the coach, after striking 
the bottom, not rolled over upon its side, it is probable 
that those within, who had not been killed outright, 
would have perished by drowning. As it was, a 
large proportion of those within the submerged cars 
escaped with their lives. It cannot be said, however, 
that these persons were all unscathed, for, though 
the woands received were in most cases not serious, 
the after-effects caused by the violent shakmg were of 
a severe character. 

Among those who developed severe symptoms a con- 
siderable time after the accident was the gentleman 
who forms the subject of this brief history. On emerg- 
ing from the water, he became conscious that the 
right shoulder and the lower portion of the back were 
somewhat stiff and sore. At the same time he felt a 
dull pain throughout the whole dorsal region. These 
IDains and the accompanying soreness in the shoulder 
soon disappeared, however, and the patient was be- 
ginning to regard himself as perfectly well, when, 
several wrecks after the accident, he complained of 
numbness in the third, fourth and fifth fingers, partic- 
ularly pronounced in the right hand. This numbness 
was accompanied by tremor of both hands, evoked 
by every attempt to execute voluntary movements. 



SPINAL IRRITATION. 173 

At the same time patient experiences ''dull, tired " 
feelings after walking even shot-fc distances, accom- 
panied by great mental depression. Co- existent with 
the above symptoms, patient has remarked a progres- 
sive decline in his sexual powers ; so that, at the time 
of visiting me, his abilities in this direction were nil. 
The testicles seemed unusually small, the scrotum 
was tightly contracted about them ; and, at the same 
time, the penis was retracted, so as to expose only 
about half an inch. Altogether the sexual apparatus 
presented the characteristics of that of a young infant. 
On examining the spine, no great tenderness could be 
discovered ; but on passing the wire brush along the 
spinous processes, from the cervical region to the sac- 
rum, an exceedingly tender pohit was discovered in 
the neighborhood of the eleventh dorsal vertebra. The 
course of this case was a long and tedious one. 

Sleep being profoundly deranged, patient was placed 
on twenty-grain doses of the bromides, to be taken 
three or four times a day. Small doses of chloral were 
also given at night during the first few weeks of treat- 
ment, combined with the tincture of liyoscyamus. 
Strychnine was not well borne, and, according to the 
patient's statement, aggravated the lumbar pain 

In order to relieve the latter blisters were applied 
throughout the painful region, but without greatly re- 
lieving the spinal soreness. Prolonged applications of 
galvanism were more effectual in relieving the irrita- 
tion ; and accordingly the constant current was applied 
every other day for two months, at the end of which 
time marked benefit had been obtained. The tin- 
gling and numbness of the limbs remained for some 
time longer ; but after the lapse of four or five months, 
it, too, had entirely vanished. Walking had also 



174 HEADACHK AND NEURALGIA. 

begun to afford pleasure, and could be indulged in 
without the fear of subsequent lassitude. 

The most difficult complication to combat in this 
case was the complete loss of sexual power, accom- 
panied by the retraction of the organ. This retraction 
of the" penis was certainly phenomenal, as akeady ob - 
served. In order to remedy the condition, dry cupping 
of the penis was resorted to, and coDtinued daily for 
over three months, and every other day for the subse- 
quent four months. By the aid of this treatment 
combined with douches, the passage of the cold sound, 
such remedies as the chloride of gold, iron and the 
coca preparations, I finally succeeded in completely re- 
storing the patient's sexual powers, so much so, in fact, 
that in due time a further addition was made to his 
family, the child, a healthy girl, weighing at birth over 
nine pounds. 

This case affords an excellent illustration of the slow 
insidious onset of the affection, of the evolution of 
severe and obstinate symptoms without local trauma- 
tism of commensurate importance, and finally of the 
ultimate success attending the treatment of what at 
the outset had all the aspects of a hopeless case. 

The patient remained under my immediate care 
nineteen months. At the end of that time, with the 
exception of occasional attacks of depression, the cure 
was complete. Since discontinuing treatment, I have 
seen the patient from time to time, and some months 
ago he informed me that these attacks of depression 
had entirely left him, and that, in short, he was as well 
as he had ever been in his life. 

The following case of Mr. Erichsen, which I cite 
from his well-known work, somewhat resembles 
the above case, which I have taken from my own 



SPINAL lURITATlON. < 176 

note book ; the termination was, however, not so 
fortunate. 

'^H. M. L., a surgeon, aged 43, naturally a stout, 
healthy man, of active i)rofessional habits, consulted 
me on February 22d, 1SG5. He stated that on October 
9th, 18G4, he was in a railway collision, by which he 
was throw^n forwards, but without any very great vio- 
lence. He received no blow on the back, head, or 
other part of the body. He was much frightened and 
shaken, but did not lose consciousness 

Beyond a general sensation of illness, he did not suf- 
fer much for the first three or four weeks after the 
accident, but he was not able to attend to his business ; 
could not collect his thoughts sufficiently for the pur- 
pose. 

About a month after the accident, he began to suffer 
from pain across the loins. He could not walk with- 
out great fatigue. He lost strength and flesh, and his 
pulse became habitually much more frequent than 
natural, being about 98 to 100. 

When I saw him four and a half months after the 
accident, he continued much in the same state ; was 
quite unfit for business, a,nd had been obliged to relin- 
quish practice ; not owing to a ay mental incapacity, 
but entirely owing to his bodily infirmities. His mind 
was quite clear, and his senses perfect, though over- 
sensitive ; loud and sudden noises and bright light be- 
ing particularly distressing to him. 

He complained chiefly of the spine. He suffered 
constant pain in the low^er part of it, in the lower dor- 
sal, and the lumbar regions. He compared the sensa- 
tion there experienced to that of a wedge or plug of 
wood driven into the spinal canal. It was a mixed 
sensation of pain and distension. The spine generally 
w^as tender, and the pain in it was greatly increased 



176 HEADACHE AND NEURALGIA. 

by manipulation, pressure and percussion. It had lost 
its normal flexibility, moved as a whole, so that he 
could not bend forward or stoop. There was no pain 
in the cervical region, or on moving the head. 

He complained of painful numbness and formications 
in the right, and occasionally down the left leg. The 
legs were stiff and weak, especially the right one. 
He could not stand unsupported on this for a moment. 
He walked in a slow and awkward manner, straddled, 
and was not able to place the feet together. If told to 
stand on his toes, he immediately fell forward. He 
had lost control over the limbs, and did not know 
exactly where to place the feet. He had a frequent 
desire to pass water, suffered greatly from flatus, and 
had completely lost all sexual desire and power. The 
pulse was at 98 ; appetite bad ; digestion impaired. 

I saw this patient again at Brighton, toward the 
end of April, seven months after the accident, in con- 
sultation with Mr. Curtis, and found that his condition 
had in no way improved. I saw him again in 1878 
with Mr. Bellamy. He had tried to follow his profes- 
sion, but was unable to do so. He had partial paraly- 
sis of the musculo- spinal nerve of the right arm, with 
atrophy of the muscles supplied by it. He had partial 
paraplegia. I believe this mischief to have been of 
chronic inflammatory nature ; the tenderness of the 
spine, the feeling of distension, the pain on movement, 
and the habitually high pulse, pointed in this direc- 
tion." 

The following is another interesting case of spinal 
concussion accompanied by great local tenderness in 
the cervical, dorsal and lumbar regions, recorded by 
Mr. Erichsen. As in the preceding case the evident 
cause was general shock. 

^'Mr. C. W. E., aged about 50, naturally a stout, 



SPINAL IRRITATION. ^ " iW 

very healthy man, weighing nearly seventeen stone, 
a widower, of very active habits mentally and bodily, 
was in a railway collision on February 3d, 1865. He 
was violently shaken to and fro, but received no bruise, 
or any sign whatever of external injury. He was 
necessarily much alarmed at the time, but was able to 
proceed on his journey to London, a distance of sev- 
enty or eighty miles. On his arrival in town he felt 
shaken and confused, but went about some business, 
and did not lay up until a day or two afterward. He 
was then obliged to seek medical advice, and felt him- 
self unable to attend to his business. He slowly got 
worse, and more out of health. Was obliged to have 
change of air and scene, and gradually, but not unin- 
terruptedly, continued to get worse, until I saw him 
on March 26th, 1866, nearly fourteen months after the 
accident. During this long period he had been under 
the care of various medical men in different parts of 
the country, and had been most attentively and assid- 
uously treated by Dr. Elkington, of Birmingham, and 
by several others, as Dr. Bell Fletcher, Dr. Gilchrist, 
Mr. Gamgee, Mr. Martin, etc. He had been most 
anxious to resume his business, which was of an im- 
portant official character, and had made many attempts 
to do so, but invariably found himself quite unfit for 
it, and was most reluctantly compelled to relinquish 
it. When I saw him at this time, he was in the fol- 
lowing state : 

"He had lost about twenty pounds in weight, was 
weak, unable to walk a quarter of a mile, or to attend 
to any business. His friends and family stated that 
he was in all respects 'an altered man.' His diges- 
tion was impaired, and his pulse was never below 96. 

" He complained of loss of memory, so that he was 
often obliged to break off in the midst of a sentence, 



17B HEADACHE AND NEURALGIA. 

not being able to complete it, or to recall what he had 
commenced saying. His thoughts were confused, and 
he could not concentrate his attention beyond a few 
minutes upon any one subject. If he attempted to 
read, he was obliged to lay aside the paper or book in 
a few minutes, as the letters became blurred and con- 
fused. It he tried to write, he often misspelt the 
commonest words ; but he had no difficulty about fig- 
ures. He was troubled with horrible dreams, and 
waked up frightened and confused. 

"His head was habitually hot, and often flushed. 
He complained of a dull, confused sensation within it, 
and of loud noises which were constant. 

'* The hearing of the right ear was very dull. He 
could not hear the tick of an ordinary watch at six 
inches from it. The hearing of the left ear was nor- 
mal ; he could hear the tick ai a distance of about 
twenty inches. Noises, especially of a loud, sudden or 
clattering character, distressed him greatly. He could 
not bear the noise of his own children at play. 

" The vision of the left eye had been weak from 
childhood. That of the right, which had always been 
good, had become seriously impaired since the accident. 
He suffered from miisccB volitantes^ and saw^ a fixed 
line or bar, vertical in direction, across the field of 
vision. He complained also of flashes, stars, and col- 
ored rings. 

" Light, even of ordinary day, was especially dis- 
tressing to him. In fact the eye was so irritable that 
he had an abhorrence of light. He habitually sat in a 
darkened room, and could not bear to look at artiflcial 
light, as of gas, candles or fire. This intolerance of 
light gave a peculiar frowning expression to his coun- 
tenance. He knitted and depressed liis brows irv order 
to shade his eyes. The sensations of smell and taste 



SPINAL IRRITATION. IY9 

seemed to be somewhat perverted. He often thought 
that he smelled fetid odors which w^ere not appreciable 
to others, and he had lost his sense of taste to a great 
degree. He complained of a degree of numbness, and 
of ' pins and needles ' in the left arm and leg, also of 
pains in the left leg, and a feeling of tightness, or 
constriction. All these symptoms were worst on first 
rising in the morning. He w^alked with great diffi- 
culty, and seldom without the aid of a stick ; whilst 
going about a room he supported himself by taking 
hold of the articles of furniture that came in his way. 
He did not bring his feet together, straddled in his 
gait, drew the left leg slowly behind the right, moved 
it stiffly and kept the foot iiat in walking, so that the 
heel caught the ground and the limb appeared to drag. 
He had much difficulty in going up and dowm stairs, 
could not do so without support. 

'^ He could stand on the right leg, but if he attempted 
to do so on the left it immediately bent and gave way 
under him so that he fell. 

" The spine was tender on pressure and on percussion 
at these points, viz., at lower cervical, in middle dor- 
sal, and in lumbar regions. The pain in these situa- 
tions was increased on moving the body in any direc- 
tion, but especially in the ant ero -posterior. There 
was a degree of unnatural rigidity, of want of flexi- 
bility, about the spine, so that he could not bend the 
body; he could not stoop without falling forward. 

"On testing the irritability of the muscles by gal- 
vanism, it was found to be very markedly less in the 
left than in the 3'ight leg 

' * The genito-urinary regions were not affected. The 
urine was acid, and the bladder neither atonic nor un- 
duly irritable. 

* ' The opinion that I gave in this case was to the effect 



ISO HEADACHE AND NEURALGIA. 

that the patient had suffered from concussion of the 
spine, that secondary inflammatory action of a chronic 
character had been set up in the meninges of the cord, 
that there was partial paralysis of the left leg, proba- 
bly dependent on structural disease of the cord itself, 
and that the presence of cerebral symptoms indicated 
the existence of an irritability of the brain and its 
membranes. 

" I saw the patient again on April ISth, 1867, two 
and a half years after the accident. He then suffered 
much from pain in the head, and in the cervical spine. 
He was subject to fits of continual depression, was 
generally nervous and little fitted for his ordinary 
business, memory was defective, and ideas uncon- 
nected. The head felt hot, face had a somewhat 
heavy expressionless look, pulse 96 to 98, digestion 
bad, urine phosphatic, left leg numb, with occasional 
darts of pain and sensation of ' pins and needles. ' It 
was colder than the right leg. ' ' 

This case of Dr. Erichsen is exceedingly interesting, 
as exhibiting the profound and persistent disturbances 
of motility and sensibility consequent upon these severe 
jars, and in the absence of all evidence of direct trau- 
matism. The persistence of the accompanying mental 
disturbances is another interesting feature. These 
derangements of memory, of concentration, of the co- 
ordinating faculty and of consecutiveness of argument 
closely resemble the characteristic group of symptoms 
present in cerebral exhaustion. I have often been 
struck by this resemblance, ajid the similitude of the 
phenomena has unavoidably led to speculations as to 
a possible identity of some of the pathological features 
of the two affections. 

The following case, extracted from my own note- 
book, is a good illustration of some of the milder phe- 



SPINAL IRRITATION. 181 

nomena sometimes evoked by concussion. As in the 
cases already cited, marked localized tenderness of the 
spine was present ; but the condition was treated in a 
more direct and effective manner. 

J. M., a married man of forty five years of age, of 
nervous temi)erament and slight physique, consulted 
me four years ago on account of a train of nervous 
symptoms, which caused him both anxiety and an- 
noyance. The salient points in his case were these : 

About eighteen months before consulting me he had 
met with an accident on the Long Branch railway. 
He was violently thrown about the car ; his head was 
cut and he received a severe bruise in the left lumbar 
region. On extricating himself from the wreckage, 
he noticed that his legs felt ' ' sleepy, ' ' and that there 
was a tingling sensation in the right side of the face. 
These sensations disappeared entirely within the fol- 
lowing week, and he was abundantly able to resume 
the duties of an active business life. All went well 
for a time ; the duties of society and business received 
a punctilious attention, which had never been excelled, 
even when the patient had been in the enjoyment of 
the most perfect health. Some five months subse- 
quent to the accident, however, he began to complain 
of great lassitude, particularly during the early morn- 
ing hours. At the same time sleep became profoundly 
deranged, and even when he was perfectly certain 
that he had slept for a few hours he complained that 
his sleep '' did him no good." Formerly of a cheerful 
disposition, he became the victim of protracted periods 
of depression ; his memory, of good average strength, 
had become so fickle, that he was obliged to carry a 
note-book, in which to record his most trivial routine 
engagements. He also suffered from soreness in the 
back and occasional attacks of facial neuralgia. 



182 HEADACHE AND NEURALGIA. 

On examination his muscular system was found to 
be weak and flabby, his heart's action feeble and irreg- 
ular and his general condition one of pronounced 
anaemia. Pressure along the spinal column revealed 
two points of marked soreness, the one in the dorsal, 
the other at the level of the second lumbar vertebrae. 
From the first of these tender spots radiated, especially 
on sudden changes in temperature, intercostal pains 
of considerable intensity. 

Having placed the patient on a tonic regimen and 
prescribed the iodide and bromide of potash, the latter 
to be taken in cumulative doses during the afternoon 
and evening, I directed my attention to the points of 
tenderness in the spine. Instead of treating them by 
the long and tedious method of local galvanization, I 
decided to try the efficacy of local injections of a coca- 
ine solution of low percentage (1^). I had abeady 
somewhat developed this mode of treatment by exper- 
iments on animals (dogs and rabbits), and on one occa- 
sion I had already made use of it in the case of a man 
suffering from spinal irritation. The injections were 
made with an ordinary hypodermic syringe and needle, 
thirty minims of a Ifo solution of the hydrochlorate of 
cocaine being deposited in the painful zone. Owing 
to the possible danger of wounding the cord, I did not 
make these injections as deeply as I desired, for at 
that time I had not developed the technique of the 
procedure sufficiently to admit of this. Later, how^- 
ever, I discovered a method of performing this part of 
the operation in the most perfect manner, without 
either danger or inconvenience to the patient.' This 
perfected technique has already been thoroughly de- 
scribed in the previous chapter; and its efficacy abun- 

' See previous chapter. Also " Scientific American Supplement" 
for Sept. 24th, 1887, and the "Medical Record" for March 17th, 1888. 



SPINAL IRRITATION. 183 

dantly demonstrated by numerous clinical histories. In 
spite of the inevitably i)rimitive nature of the proced- 
ure, I succeeded in affording much relief to the pa- 
tient ; so that, after the injections had been repeated 
a few times, the soreness disappeared entirely. 

Wlien I compare the promptness of the relief ob- 
tained in this case with the long course of palliative 
treatment required in the case detailed at the begin- 
ning of this chapter, I am the more surprised that 
greater efforts have not heretofore been made to affect 
the functions of the cord by resort to more effective 
and direct methods. 

Having thus detailed some of the painful complica- 
tions often encountered in even the milder phases of 
concussion of the spine, it now becomes necessary to 
leave this interesting portion of the subject ; for, it is 
self-evident that to pursue the matter further would 
be to transcend the natural limitations of a dissertation 
of this sort. 

As to the subject of local medication in its truest 
sense, that is the bringing of medicinal substances 
into the immediate vicinity of or in direct contact 
with the cord, in contradistinction to measures applied 
at a distance from the latter, as upon the integument, 
I can only say that judged by results, the improved 
procedure is inevitably destined to play a conspicuous 
part in the u euro-therapeutics of the future. 



PART V. 



ISTormal and Morbid Sleep. 



CHAPTER XXVIII. 

CONSIDEKATIONS ON THE PHYSIOLOGY OF SLEEP. 

I HAVE already had occasion to allude i^epeatedly, in 
different portions of this work, to th(3 important part 
which derangements of sleep play ii] intra and extra- 
cranial head-aches, and indeed in all forms of pain. 
Mention has also been made of the great benefits to be 
derived from the skillful use of prolonged sleep, in the 
treatment of all varieties of head-pain. 

A proper understanding of sleep is, therefore, quite 
as necessary to the physician who would treat those 
painful affections propeiiy as to the alieuist engaged in 
the management of mental disorders. The cod eluding- 
portion of this treatise will, therefore, be devoted to 
the consideration of the more important phases of nor- 
mal and morbid sleep. 

As a preliminary to the consideration of the more 
intricate questions, a discussion of the physiological 
factors involved will prove useful. 

Sleep may be defined in general terms as that state 
of the central nervous system in which the higher 
centres are, to a great extent, in a condition of physi- 
ological quiescence, with all the consequences thereby 
iaiplied. In its most profound form, and probably in 
it most perfect manifestation, there is a total cessation 
of the strictly psychical functions. The automatic and 
reflex centres, on the contrary, are active, so that the 
functions dependent thereon— such as respiration, cir 
culation, digestion, secretion, etc. — are regularly car- 



188 HEADACHE AND NEURALGIA. 

ried on. Again, the re- actions to external excitation 
must be considered as systematized reflex actions, as 
they are in every respect similar to the automatism 
observed in decapitated animals. Judged from an ex- 
perimental standpoint there is indeed no reason why 
tiiese phenomena should not occur even with a certain 
degree of apparent objectiveness, without necessitating 
the intervention of the strictly psychical centres. 

During the early history of medicine everything 
pertaining to sleep was regarded with more or less 
superstition, and the theories propounded respecting 
the nature of the same were as a rule of the most fan- 
tastic nature. It is, indeed, only within comparatively 
recent years that experimental physiology has essayed 
the solution of a problem, which even to investigators 
of ripe understanding seemed little short of hopeless. 
The difficulties with which the subject is inevitably 
environed are certainly great, and scientific progress 
has of necessity been slow, in spite of the efforts of 
even the most original minds. At the jDresent day, how- 
ever, a survey of the investigations which have been 
made in this department of phsyco- physiology cannot 
fail to cause gratification at the substantial and 
durable nature of the acquisitions. Among the most 
important experimental contributions to the physi- 
ology of sleep are those which have served to exhibit 
the relation of the intra-cranial blood-stream to the 
cerebral protoplasm. 

There can be no doubt that the ancients entertained 
certain theories respecting the relation of the carotid cir- 
culation to the function of sleep. Thus, in an interest- 
ing paper, Pilz' refers as follows to the knowledge pos- 

' "Zur Ligatur der Arteria Carotis Communis," von Dr. C. 
Pilz, Langenbeck's Archives fiir Klinischie Chirurgie, vol. IX., p. 
406. 1868. 



THE PHYSIOLOGY OF SLEEP. 189 

sessecl by Rufus of Epliesus respecting the influence 
exercised by digital compression of the carotids upon 
the function of sleep. "Arterias per coUum subentes 
carotides, id est somniferas, antiquos nominesse, quo- 
niam compressae homineni sopore gravabant . ' ' ' These 
early accounts of compression are, however, enveloped 
in a veil of uncertainty; and whatever use the ancients 
may have made of the procedure seems to have been 
speedily forgotten by subsequent writers. At all 
events, comparatively little is to be found in literature 
upon the subject until the close of the eighteenth cen- 
tury, when Parry, of Bath (1792), again directed the 
attention of the profession to the efficacy of digital 
compression of the carotids, as a means for the allevi- 
ation of convulsive disorders. The publication of this 
paper seems to have added a new impetus to the sub- 
ject; and the result is a series of papers, extending 
over a .period of seventy-five years. In 1819 Dr. M. 
Bland pubhshed some interesting cases, illustrative of 
the efficacy of digital compression of the carotids in 
cerebral disorders characterized by engorgement. 

Twenty years later Dr. J. B Stroehlin ' pubhshed an 
article upon the same subject. In an article published 
in 1841, Dr. Troudeau' calls attention to the great effi- 
cacy of digital compression of the carotids in convul- 
sive disorders. A case of acute meningitis is cited, in 
which the author essayed digital compression of the 
carotids with good results. 

Reference is also made to the discussioa. respecting 
the priority of the discoveiy of digital compression, 
which ensued upon the publication of MM. Trous- 
seau's, Baudelocque's, and Malapert's papers. In the 

^ Morgagni, de sedibus et eaus. Morb. epist. 19, quoted by Pilz. 

^ "Medical Examiner," April, 1841. 

2 " Journal Medico-Chirurgical " of November, 1840. 



190 HEADACHE AND NEURALGIA. 

paper of Dr. Dezeimeris, which appeared about the 
same time, the credit of the discovery of the therapeu- 
tic value ol digital compression is awarded to Parry, of 
Bath. In 1S4S Waller ' published an essay on the uses 
of digital compression, in which, while praising the 
procedure in the highest terms, he expresses regret 
that the difficulty often experienced, in adapting the 
fingers to the contours of the arteries, should be so great. 

Seven years after the publication of the paper of 
Waller, Fleming^ instituted some experiments, with a 
view to ascertaining the physiological effects of com- 
pression. By exercising pressure with the fiagers 
upon the carotids this observer was able to produce 
sleep on several occasions. 

During the same year Dr. T. W. Mc Arthur ' pub- 
lished a paper upon the therapeutic effects of the pro- 
cedure, in which he expresses the conviction that com- 
pression of the carotids is beneficial in at least some 
convulsive diseases. 

In 1S60 Durham* ascertained by direct observation 
that the amount of blood circulating in the brain is 
reduced in quantity during sleep. His experiments 
were perfornred in the following nranner: A circular 
opening was made in the skull of a dog with a tre- 
phine, care being exercised not to cause injury to the 
membranes. A portion of the dura was then carefully 
removed, so as to expose the vessels of the pia mater 
aird a watch-glass cemented over the openirrg. 

' "IMedical Counsellor," September, r855. 

' An article by Dr. Alexander Fleming, "British and Foreign 
Medico-Chirurgical Review," April, 1855. 

2 " On Compression of the Carotids — Its Effects on Headache, 
etc.," by Augustus Waller, M.D., "Journal of Psychological Med- 
icine." London, 1848. 

" "The Physiology of Sleep," by Arthur L. Durham. " Guy"s 
Hospital Reports," vol. vi., 18G0. 



THE PHYSIOLOGY OF SLEEP. lUi 

When the animal was awake the vessels of trie pia 
were ohserved to be moderately distended, whereas 
during sleep the brain was somewhat retracted and 
presented a pale appearance. 

The contrast in the appearance o£ the oi-gan during 
activity and repose is said to have been remarkable. 

This paper belongs in the category of the most im- 
portant contributions to the physiology of cerebration. 
The author's critical interi)retation of the plienom- 
ena is masterly and is well worthy of careful perusal. 
This is not the place, however, to enter into an analysis 
of the inferential data of the paper. Five years after 
the publication of the experiments of Durham, Dr. 
Guibert' gave expression to his views regarding the 
value of digital compression of the carotids as a thera- 
peutic agent, noting with regret the evident neglect 
which this valuable procedure had met with at the 
hands of the pi'ofession. 

In 1869 Hammond ' published the results of a series 
of experiments, undertaken with a view to ascertain- 
ing the amount of cerebral pressure present during 
sleep, as well as during wakfulness. The experiments 
were performed upon dogs and rabbits, by the aid of 
an instrument called the '^cephalohaemometer," in- 
vented by the author. This appliance '^consists of a 
brass tube, which is screwed into a round hole made 

in the skull with a trephine Both ends of the 

tube are open; but into the upper is screwed another 
brass tube, the lower end of which is closed by a piece 
of very thin sheet india-rubber, and the upper end 
with a brass cap, into which is fastened a glass tube. 

^ "De La Ligature et de la Compression des Artires Carotides," 
"Union Medicale," January, 1865. 

^ " New York Medical Gazette and Quarterly Journal of Psycho- 
logical Medicine and Medical Jurisprudence," January, 1869. 



192 HEADACHE AND NEURALGIA. 

. . , The inner arrangement contains colored water, 
and to the glass tube a scale is affixed. . . . This 
second glass tube is screwed into the first, till the thin 
rubber presses ui)on the dura mater, and the level 
of the colored water stands at 0, which is in the mid- 
dle of the scale. ' ' It was found that when the ani- 
mal is asleep, the liquid falls in the tube, indicating 
that a diminution in cerebral pressure has taken place. 
Now, since the pressure is in direct proportion to the 
quantity of blood circulating in the brain, diminution 
of the former can only take place in consequence of a 
reduction in the amount of intra-cranial blood. When 
the animal awakes the liquid in the tube is seen to rise 
at once. Thus, by virtue of the results obtained by 
Hammond, the experiments of Fleming and Durham 
receive substantial confirmation. 

Schiff ' has found by direct measurements performed 
upon the brain, that a local development of heat takes 
place in the particular district where an impression is 
disseminated. And he has furthermore ascertained 
that this local development of heat is a dynamic phe- 
nomenon, quite distinct from any mere activity on 
the jjci^^t of the circulation. We have in a word to do 
with an evolution of heat in the psychical centres 
which takes place on the advent of the sensorial im- 
pression. The direct and indirect value of these inves- 
tigations of Schiff to psycho-physiology it is difficult 
to overestimate. 

Lombard and others have shown that during active 
mentalization the temperature above the skull rises. 
The thermo-electric instrument employed by Lombard 
in these investigations is extremely ingenious; a de- 
scription of the same is contained in the '' British Med. 
Journal," 1875. 

' " Archives de Physiologie," 1870. 



THE PHYSIOLOGY OF SLEEP. 193 

Several years ago, while yet entirely ignorant of the 
experimental researches of Fleming and Durham, I 
was led by considerations of a purely theoretical 
nature to inaugurate a series of experiments witli the 
object of determining the effects produced by pressure 
applied to the stems of both carotids. My first at- 
tempts at compression were made with the fingers; 
but I soon became aware of the inherent defects of 
this method. Ere long, however, the thought sug- 
gested itself to me that an instrument might be de- 
vised which would effectually obviate the disadvan- 
tages of the digital method. ' Accordingly after many 
trials I succeeded in constructing an appliance with 
which I was not only able to conduct some highly 
instructive experiments, but likewise to add a chapter 
to the therapeutics of epilepsy, acute mania, and 
certain functional cerebral disorders, characterized by 
vascular derangements. Without entering into the 
details of these investigations, which have long since 
received extensive recognition both in this country and 
abroad, I will briefly summarize the more important 
physiological phenomena which they served to exhibit. 
When pressure was made upon both carotids with the 
instrument above referred to, the fii'st symptom which 
attracted my attention was marked facial pallor. As 
the degree of compression was gradually increased 
there was marked drooping of the eyelids, accompanied 
by dizziness. These symptoms were soon followed by 
retardation of respiration and cardiac action, while at 

^ For a description of this instrument and for an account of the 
experiments performed with it see " Medical Record " of February 
18th, 1882. Also, "Carotid Compression," by J. Leonard Corning, 
M.D.; Anson D. F. Randolph & Co., New York, 1883. Finally: 
'' Electrization of the Sympathetic and Pneumogastric Nerves 
and Carotid Compression." Ibid. *'New York Med. Jour.," Feb. 
22d, 1888. 

13 



191 HEADACHE AND NEURALGIA. 

the same time, in a considerable proportion of cases, 
the subjects complained of a heavy, drowsy sensation. 
So overpo^vering was this soporific tendency in some 
subjects that a condition closely simulating if not 
actually equivalent to sleep was produced. In very 
anaemic persons it was possible to produce an instan- 
taneous condition of syncope; while in several cases of 
acute congestive mania I was enabled to produce a 
condition which, as far as I was able to ascertain, was 
identical with natural sleep. With the idea of elimi- 
nating all sources of error which might be conceived 
as arising from contiguous nerve- stems, I had con- 
structed a large cylindrical apparatus, by means of 
which it was possible to enclose the lower extremities 
hermetically. An air-pump, attached to the appara- 
tus by means of a rubber hose, enabled the experimen- 
ter to exhaust the cylinder to any desired degree. With 
this apparatus, I was enabled to produce retardation 
of respiration, and cardiac action, as well as marked 
soporific phenomena in some cases.' 

Finally, the experiments of Nounyma and J. Schrie- 
ber^ have shown that, when the amount of intra-cranial 
blood is increased, there is a corresponding diminution 
in the quantity of cerebro spinal fluid within the skull, 

' For an account of these and other investigations vide " Medical 
Record;^ Feb. 18th, 1882; an article on " Sleep," " Medical Record," 
July, 1882. A monograph on " Carotid Compression," Anson D. 
F. Randolph & Co., New York, 1882. A paper read before the 
New York Neurological Society June 6th, 1882, and published in 
the "Philadelphia News" of June 17th, 1882, and in the "Ameri- 
can Journal of Neurology and Psychiatry, 1882. Also a paper on 
" Electrization of the Sympathetic and Pneumogastric Nerves," 
with Simultaneous Bilateral Compression of the Carotids, "New 
York Medical Journal," Feb. 23, 1884. 

^IJber Gehirndruch von Nounyma and J. Schreiber, Leipzig: 
F. C. W. Vogel, 1881. 



THE PHYSIOLOGY OF SLP^EP. Ilj5 

owing to a deviation of the liquid in the direction of 
the spinal subarachnoid space. 

These experiments prove beyond question that the 
degree of sanguineous irrigation of the encephalon is 
in direct proportion to the amount of functional activ- 
ity of the organ. When the activity of the brain is 
greatest, the hyperaemia of the meninges obtains a 
maximum degree of intensity; whereas, during the 
functional quiescence of sleep, the amount of blood 
circulating in the vessels of the pia mater is at a min- 
imum. That this relation of the blood -stream to the 
cerebral plasma is not one of mere concomitance, but 
rather the outgrowth of the functional necessities of 
the cerebral cell itself, is proven by the immediate 
diminution in the intensity of brain function, which 
ensues upon compression of the carotids. Even where 
the protoplasm of the ganglia is in an unstable condi- 
tion, as in epilepsy, it is possible, as proven by the ex- 
perimental observations of Stroehlin, Trudeau, Waller, 
McArthur and myself, to arrest the convulsions to 
which the unusually explosive condition of the cere- 
bral parenchyma gives rise, by pressure upon the stems 
of the common carotid arteries. 

The ebb and flow of the intra- cranial blood- stream, 
then, is contingent upon the functional necessities of 
the ganglia. Cerebration is essentially a process of 
oxydation. Inversely, sleep is that condition in 
w^hich oxydation within the ganglia is at a mini- 
mum. The unconsciousness, which is the character- 
istic feature of sleep is, therefore, nothing more than 
the expression of a decline in the processes of meta- 
morphosis within the brain cell. The local cerebral 
anaemia, the retarded heart beat, and the infrequent 
respiration are at once the direct consequent of, and 



196 HEADACHE AND NEURALGIA. 

indispensable requisite to, the decline of cerebral meta- 
morphosis. 

As to the more intimate natm^e of the metamorpho- 
sis incident to cerebration, but little is known with 
certainty. Hammond ' has conducted a series of care- 
ful urinal analyses, for the pmpose of ascertaining the 
changes in the composition of the urine incident to 
increased mental ization. From these experiments he 
is led to draw the following conclusions: 

(1.) That increased mental exertion augments the 
quantity of urine. 

(2.) That, by its influence, the urea, chlorine, and 
phosphoric and sulphuric acids are increased in quan- 
tity. 

(3.) That the uric acid, on the contrary, is very 
materially reduced in amount. 

(i.) That diminished intellectual exertion produces 
effects directly contrary to all the above. 

More recently, Byasson ' has demonstrated that the 
activity of the ganglia is accompanied by an expendi- 
ture of phosphorized material, and, furthermore, that 
this waste product of brain activity is eliminated from 
the organism through the urine, in the form of phos- 
phates and sulphates. In addition this observer found 
that the amount of phosphates and sulphates secreted 
stands in a certain ratio to the quantity of mental 
energy expended; and that, in a word, the above 
waste products could be utilized as a measure of the 
amount of brain work accomplished in a given length 
of time.' 

' "Urological Contributions," "The American Journal of the 
Medical Sciences," April, 1856. 

'^" Journ. danat. de Robin," 1809. 

3 For a more detailed account of these experiments than is ad- 
missible in a work of this character, see my monograph on " Brain 
Exhaustion," D. Appleton & Co., New York, 



THE PHYSIOLOGY OF SLEEP. IDT 

Dr, Eobert J. Edes has very recently published a 
series of experiments by which it is souglit to i)rove 
"that the amount of phosphates derived from the 
metamorphosis of brain-tissue in the condition of phy- 
siological activity is so small, in comparison with that 
from the system generally, that it has no perceptible 
effect on the total of phosphates found in the urine." 

Owing to the lack of system observed in these ex- 
periments with regard to diet, physical exercise and 
sleeping, it is impossible to accept the results obtained 
as either confirmatory of or opposed to the researches 
of Byasson and others. Until, therefore, more sub- 
stantial scientific evidence to the contrary is forth- 
coming, we must accept the conclusions arrived at by 
these gentlemen. A more extended criticism of these 
experiments has been given in my monograph on 
cerebral exhaustion, previously referred to, and I shall 
therefore abstain from pursuing the discussion further 
on the present occasion. 

If, then, it be admitted, that the greater the expen- 
diture of cerebral force the greater is the excretion of 
phosphates and sulphates, we are bound to assume 
conversely that the quantity of these products de- 
creases proportionately with a decline in mentahza- 
tion. Since, therefore, sleep is the expression of a 
minimum of cerebration, it follows, as a natural conse- 
quence, that during its continuance, the excretion of 
phosphates and sulphates must be smaller in amount 
than mider any other circumstances. 

It is true, nevertheless, that if dreaming and uncon- 
scious cerebration be accepted as accompaniments of 
normal sleep, the integrity of the above argument is 
vitiated to a certain extent; for doubtless both dream- 
ing and unconscious cerebration represent the output 
of no little energy on the part of the cerebrum. 



198 HEADACHE AND NEURALGIA. 

Hence the great lassitude observable after sleeping in 
those who are addicted to excessive dreaming, night- 
mare or unconscious cerebration. For my own part, 
I cannot consider any one of these last-named phe- 
nomena as constituting an accompaniment of the nor- 
mal type of sleep strictly considered. As above inti- 
mated, nothing is more certain than that those who 
suffer from nightmare, persistent dreaming and un- 
conscious cerebration awake from sleep far less 
refreshed than those who suffer from none of these 
psychological encumbrances. I could cite many cases 
occurring in my own experience illustrative of this 
fact. A common complaint on the part of such indi- 
viduals is that although they have slept a sufficient 
number of hours, they nevertheless experience no 
benefit, and awake totally unrefreshed, and entirely 
unprepared for the activities of the day. Dreaming, 
unconscious cerebration, and nightmare, will there- 
fore be considered, in the following discussion, among 
the obvious, though less serious anomalies of sleep. 
To sum up the evidence, already adduced, we find 
that the essential factors of sleep are: 

1. Exhaustion of the available energy of the cerebral 
cell, by which it is to be understood that the explosive 
material, hoarded up during a former period of uncon- 
ciousness, has become oxydized, and is no longer in a 
condition to support the chemical process incident to 
function. As a consequence we have a decline of all 
the intellectual processes, and finally complete loss of 
consciousness, accompanied by a fall in temperature.^ 

^ As shown by Shiff , the rise in temperature, which accompanies 
intellection, is not alone attributable to the local hyperaemia, but 
must be ascribed in part, at least, to the increased metamorphosis 
which takes place within the cell itself. Inversely, it is evident, 
that the fall in local temperature, observable during sleep, is not 



THE PHYSIOLOGY OF SLEEP. 199 

2. "Retrocession of the intra-cranial blood-stream, 
resulting in more or less pronounced ana3mia of the 
ganglia. 

3. Decline of oxydation within the ganglia. 

4. Retardation of tlie lieart's action. 

5. Decline in the rai)idity of respiration. 

6. Concomitant with the decline of oxydation a 
gradual re-accumulation of explosive material takes 
place within the ganglia. 

From a consideration of the foregoing physiological 
factors, it will be seen that during sleep the processes 
of integration predominate over those of disintegra- 
tion; whereas during waking the opposite condition 
prevails. The most important f miction of sleep then 
is to counteract the ganglionic waste incident to 
cerebration. 

A thorough comprehension of the physiological sig- 
nificance of sleep is absolutely indispensable alike to 
the rational understanding and treatment of all forms 
of mental derangement. Moreover, the various phases 
of insomnia are only amenable to rational treatment, 
by virtue of a correct appreciation of the various phy- 
siological factors of normal sleep. 

CLASSIFICATION OF INSOMNIA. 

The following division of insomnia into two princi- 
pal groups is justifiable, at least from a cHnical stand- 
point. Moreover, while fulfilling the exigencies of 
practice it will be found to be in essential harmony 
with the physio -pathology involved. Insomnia may 
be divided, then, into an idiopathic and into a symp- 
tomatic variety. Idiopathic (primary) insomnia is 

alone a consequence of the anaemia, but must be ascribed in part 
to a decline in the intensity of the dynamic processes within the 
cells themselves. 



200 HEADACHE AND NEURALGIA. 

that form of sleeplessness, the predisposing cause of 
which cannot be traced to any particular source extra- 
neous to the brain itself. Symptomatic (secondary) 
insomnia is that form of the disorder which may be 
observed in the course of many acute and chronic dis- 
orders. Under this head may also be considered that 
form of the affection which arises from a more or less 
severe degree of pain. 



CHAPTER XXIX. 

IDIOPATHIC INSOMNIA. 

Etiology. — The most important causes of this pre- 
eminently important variety of the affection are ex- 
cessive emotional disturl)ances coniLined with overtax- 
ation of the intellectual faculties. 

Among the foiTaer are profound sorrow, jealousy, 
fear, heavy responsibility, disappointed ambition, sus- 
pense, sudden pecuniary losses, and in short every 
factor which acts with sudden intensity upon the cen- 
tres of ideation and emotion. 

There is probably no single cause so liable to result, 
if unchecked, in permanent impairment of the cere- 
bral apparatus, as this form of insomnia. It is a fact 
of the highest theoretic and practical importance, that 
not only do the lesser forms of functional impairment 
of the intellectual mechanism begin with some de- 
rangement of sleep, but also those graver forms of 
mental derangement, usually included under the des- 
ignation of insanity, are almost invariably preceded by 
more or less chronic insomnia. The wear and tear 
incident to business and professional competition, as 
well as the involved nature of the social conditions of 
modern life have much to do with the prevalence of 
the disorder. The above proposition is amply substan- 
tiated by the statistics of insane asylums and hospi- 
tals. In view of these facts it is hardly necessary to 
insist upon the important relation sustained by dis- 
orders of sleep to cerebral economics and pathology. 



202 HEADACHE AND NEURALGIA. 

Symptoms. — These consist in great lassitude during 
the day, coupled with a high degree of irritability, 
which is particularly well marked in the morning. 
The skin has usually a dead, sallow appearance and 
the eyes are sunken and devoid of their normal lustre. 
The urine is often scant and highly colored, and a con- 
stipated habit is the rule. Sometimes, however, tbe 
subject is afflicted by an obstinate diarrhoea, which 
contributes not a little towards his general enfeeble - 
ment. So great is the lassitude in severe cases that 
the patient reclines upon the sofa the greater part of 
the day, or wanders about the apartment, unable to 
summon energy sufficient to perform even the most 
trivial task. Uncontrollable yawning is present in 
almost every case. When expostulated with, on ac- 
count of his listlessness. the subject becomes morose 
and sullen, refusing in the most peremptory manner 
to listen to the counsel of those about him. The 
small ills of life assume commanding proportions, and 
even the most trivial occurrences are distorted, and 
magnified to an inordinate degree. On retiring the 
subject is unable to sleep. He tosses from side to side, 
removes the bed-clothes, changes his position contin- 
ually in the vain endeavor to become unconscious. 
The peripheral irritation occasioned by his contortions 
only serves to perpetuate the condition of cerebral 
erethism. When, as frequently happens, sleep at last 
supervenes, it is no longer physiological in character, 
but, on the contrary, perverted by dreams a,nd uncon- 
scious cerebration to such a degree that it affords little 
or no refreshment. Daylight finds the individual 
completely prostrated, and unable to resume his accus- 
tomed activities with the requisite amount of energy. 

Under these circumstances resort is had to stimulants 
of all kinds. Strong coffee, tea, brandy and even mor- 



IDIOPATHIC INSOMNIA. '2()^> 

phine are tried, witli tlio hope of afToidiiiti; a renewal 
of vigor. But the relief obtained is at most transi- 
tory in character, and the reaction, which inevitably 
follows, leaves the subject in a far worse condition 
than before. Where tlie temperament of the patient 
is abnormally emotional, the insomnia is of a far 
graver character than where the cast of mind is es- 
sentially intellectual. Adv^ersity, worry and suspense 
are not well endured by such persons; and even trivial 
disappointments give rise to all manner of dismal 
forebodings. The cares of the day, instead of being 
abandoned at bed -time, take entire possession of the 
mind, and effectually exclude sleep. It is, moreover, 
an unfortunate circumstance that the occupations 
usually preferred by this class of individuals are such 
as appeal powerfully to the emotions; and thus the 
mind is kept in a perpetual state of erethism. 

On the other hand, those in whom the ratiocina- 
tive faculties assume great prominence, though sub- 
ject at times to attacks of insomnia, are far less liable 
to become victims of chronic wakefulness than those 
in whom the emotional faculties are predominant. 
Moreover, the insomnia peculiar to the former class 
of persons is not usually accompanied by the extreme 
mental irritation which is so constant and painful a 
symptom of the emotional type of sleeplessness. 

A vivid imagination is also extremely prone to ag- 
gravate an attack of insomnia. The fancy, instead of 
becoming gradually subdued, until the supervention 
of unconsciousness, increases in activity; while myiiads 
of fantastic thoughts crowd upon the mind in endless 
procession, and baffle every attempt at repose. Those 
possessed of great imaginative powers and strong 
emotions are particularly dependent upon sleep. De- 
prived of the latter, they become listless, irritable and 



^Ott HEADACHE AND NEURALGIA. 

emaciated; and in an incredibly short time the ardor 
of even the most sanguine dispositions is entirely 
quenched. During the early part of the night such 
persons lie awake for several hours, tormented by a 
constant succession of thoughts and emotions of the 
most varied character, and not till towards morning 
do they usually succeed in falling asleep. This sleep, 
though short in duration, is far from physiological in 
character, being accompanied in most instances by a 
succession of morbid dreams, which are th3 direct out- 
grow^th of the previous condition of mental extrava- 
gance. 

On awaking, complaint is made of sensations of 
heaviness, of head pains, which may be variously loca- 
ted, or of a feeling of constriction about the forehead. 
Sometimes a sensation of distention is noticed in the 
region of the vertex, which may or may not be accom- 
panied by pain. 

There is a large class of persons in cities, employed 
in hotels, theatres, and other public places of resort, 
who from the nature of their employment are com- 
pelled to remain awake during the whole or a greater 
portion of the night. It is the habit of these individ- 
uals to seek to compensate for the loss of sleep entailed 
by their various nocturnal employments, by resort to 
day sleep. Such repose, is, however, both as regards 
duration and quality, far inferior to the normal sleep 
enjoyed at night; and the persons who are compelled 
to resort to it are rarely if ever able to compete in 
energy or endurance with those whose employments 
permit them to retire soon after sunset. They be- 
come either sallow and emaciated in appearance, or 
pale and flabby, especially when addicted to the use of 
alcoholic stimulants. As to the sleep itself, not only 
is it deficient, as we have seen, in ultimate restorative 



IDIOPATHIC INSOMNIA. 



205 



effect, but also with regard to quality. Morbid 
dreams, unconscious cerebration, and nightmare are 
the usual accompaniments of day sleep. In the ma- 
jority of cases, persons whose only alternative was the 
form of sleep just described, have been obliged, after 
the lapse of but a few years or even months, to desist 
from the nocturnal employment and adopt some other 
form of occupation. 






CHAPTEE XXX. 
SECONDARY INSOMNIA. 

SLEEPLESSNESS ARISIXG FEOM IRRITATIOiT OP THE CEN- 
TRIPETAL XERYES. 

In order to insure the most ^Derfect form of natural 
slee^D, there should be, as far as possible, an absence of 
sensory imjDressions. When there exist neither imta- 
ting disorders within the body nor upon its sm-face, 
and when no impressions are transmitted through the 
special senses, it is evident that the requirements of the 
above proposition are fulfilled. During normal sleep, 
it is true, the receptive centres are blunted because of 
the exhausting effects of the previous stage of activ- 
ity. As a consequence, moderate sensory impressions, 
which drudng the waking condition w^ould have led to 
active perceiDtion, leave no imjDrint upon the exhausted 
protoplasm. ^^Hien, however, impressions of consid- 
erable intensity are transmitted to the exhausted re- 
ceptive centres, the latter become irritated and aroused 
from the lethargy consequent upon exhaustion, and 
finally the entire cerebral mechanism is aroused — the 
individual is awakened. 

Tliis is the essental morbid physiology of w^hat I 
have considered under the head of secondary or symp- 
tomatic insomnia. 

Dr. Eobert J. Graves ' has given an excellent de- 

' Clinical Lectures, hy I)r. Eobert J. Graves, second American 
Edition: Ed. Barrington & Geo. 1). Howell, Philadelphia, 184?. 



SECONDARY INSOMNIA. 207 

scription of tlie insomnia i)ro(luce(l by tlie api)lication 
of blisters. Such cases are practically e;x:periniental cor- 
roboration of the views advanced by myself with regard 
to the nature of symptomatic insomnia. Moreover, 
they serve to illustrate the anti-soporific effects pro- 
duced by irritation of the peripheral organs of centri- 
petal nerves. In speaking upon this subject, Dr. 
Graves observes: — '' The bad effects on the nervous sys- 
tem occasionally produced by the application of blis- 
ters, are somewhat analogous to those which result 
from wounds and other external injuries, and to be 
accounted for on the same principle. . . . Wounds 
and injuries sometimes make an impression on the 
nervous system by no means proportioned to the im 
portance of the injured organ to life, or to the extent 
of the mischief. . . . An injury produced by a body 
which strikes the sentient extremities of the nerves 
with great force will sometimes produce very remark- 
able effects on the system. . . . Thus a musket ball 
striking a limb may, without wounding any great 
artery or nerve, or destroying any part of importance 
to life, produce a train of nervous symptoms of an ex- 
traordinary character. The person, without feehng 
much pain, and scarcely knowing that he has been 
wounded, without being terrified, or having his imag- 
ination excited by an apprehended danger, turns 
pale, gets a tendency to faint, and sometimes actually 
dies from the impression made on the nervous system. 
... In the same way an exteriial hijury (or even a 
comparatively slight impression') reacting on the 
nerves (and centres of perception) may bring on high 
mental excitement, delirium, and a total privation of 
sleep. The delirium and sleeplessness arising from 
blisters is by no means an uncommon disease." 

' The pareiitlietical remarks are mine, J. L. C. 



208 HEADACHE AND NEURALGIA. 

The majority of cases of secondary insomnia are 
traceable to some irritative process affecting the ter- 
minal organs of the centripetal nerves, or to some acute 
or chronic form of organic disease, by w^hich a vast 
number of sensory nerves are kept in a more or less 
continuous state of irritation. 

If the pathological physiology advanced by myself be 
accepted, it v^ill readily be understood why acute and 
chronic affections should produce obstinate sleepless- 
ness, even where no considerable degree of pain is 
present. Furthermore, the views expressed by Dr. 
Graves concur with mine in every particular. 

Among the diseases which most frequently produce 
insomnia are : Cutaneous affections, acute and chronic 
pulmonary diseases, neural hypersesthesia (neuralgia), 
stomachic disorders, syphilis and fevers. It is suffi- 
ciently obvious also that pain, whatever may be its 
origin, is one of the most prolific sources, if not the 
most prolific cause of insomnia. Again certain forms 
of kidney and hepatic troubles may produce more or 
less protracted wakefulness. 

Without pursuing the subject in all its ramifications, 
which would be a useless loss of time as far as any 
practical benefit is concerned, it will be well to bestow 
a glance upon the various forms of morbid dreams, 
which are so constant an accompaniment in almost all 
cases of wakefulness. 



CHAPTER XXXI. 

CONSIDERATIONS ON DREAMS. 

The composition of dreams is determined in great 
measure by the individuality of the subject, and by the 
sum total of the impressions of which he has been the 
recipient. As to the contents of a particular dream, 
it is a matter of common experience that the acciden- 
tal emotions and ideas, present in the mind previous to 
retiring, exert a determining influence upon its consti- 
tution. All the multifarious factors of the mental life 
of the individual— all that he has felt, willed, or expe- 
rienced—may be revived in his dreams. 

The impressions which may give rise to dreams by 
acting upon the individual during sleep are of various 
kinds. In the first place the impressions which act 
upon the central ganglia through the five senses very 
often give rise to dreams.* Secondly, the subjective 
excitation of the senses, as well as muscular sensa- 
tions and general impressions of the most varied char- 
acter, may result in the production of dreams. Even 
where a certain sense is closed to outward impressions, 
the individual is by no means necessarily deprived of 
the sensations and ideas arising from the same when 
in a normal condition. Thus Esquirol ' mentions the 
case of a man who when forty-one years of age was 
afflicted by double cataract, and who nevertheless be- 

^ Vide the opinions entertained by Schopenhauer relative to this 
point, Parerg. und. Parahpom. Leipzig, 1877. 
2 Cited by Radestoek. 
U 



210 HEADACHE AND NEURALGIA. 

came enraged with persons whom he supposed he saw. 
Blester relates that there Hved in Anspach, not many 
years since, an old midwife entirely blind, who com- 
plained tliat she was troubled not by ghosts, but by 
the frequent appearance of animals and men. The 
apparitions were quite as vivid as though she were in 
full possession of the power of vision. ' 

Malposition of the body, indigestion and other 
causes which tend to impede the circulation are said 
by some to give rise to cardiac palpitations, difficulty 
of respiration, and, when the phenomena are very pro- 
nounced, to nightmare. While willing to admit that 
such may often be the case, I feel compelled to affirm 
that I have known of many cases of nightmare in 
which no such factors as malposition of the body in 
bed or indigestion could be ascertained. Indeed the 
only possible assignable cause of the disorder was a 
condition of cerebral irritation or exhaustion. It is 
my firm belief that precisely as palpitations and diffi- 
culty of respiration are produced by excessive emotions 
during waking, so the same derangements may be 
caused during sleeping as a result of the excessive 
emotional disturbances often present during dreams. 
"Where the subject of dreams is of a neurotic tempera- 
ment or a sufferer from cerebral exhaustion or irritabil- 
ity, the influence of purely psychological disturbances 
(whether occurring during w^aking or as accidents of 
sleep) upon the respiratory, cardiac and general bodily 
functions, is far greater than in those of more robust 
constitution. Among ancient and mediaeval peo- 
ples the frightful phenomena of nightmare were as 
cribed to some supernatural agency, and demonology 
and witclicraft have at all times received substantial 
support from the same frightful source. The inhabi- 

' Berliner Moriatssclirift, October, 1800. 



CONSIDERATIONS ON DREAMS. ', 211 

tants of New Zealand regard the apparitions of dreams 
as hurtful deities, and similar opinions are entertained 
by some of the tribes of Central America and by some 
of the inhabitants of the coast of Africa. 

So excellent an authority as Augustin believes that 
the visits of the incubi have been attested by so many 
competent witnesses, that a further denial of the fact 
is impossible. 

The following narrative, recorded by Raoul Glaber, 
embodies such a grapliic illustration of nightmare, 
that I give it in full, in lieu of further description: 
** One niglit towards early morning, I saw, sitting at 
the foot of my bed a little monster of hardly human 
shape. It appeared to me to be of medium size, thin 
necked, emaciated form, vv^ith black eyes and a narrow 
wrinkled forehead. The nose was broad, the mouth 
large, the lips thick, and the chin short and sharp. A 
goat's beard, straight pointed ears, dirty dry hair, dog's 
teeth, pointed occiput, projecting breast, hump back, 
withered loins, and dirty clothes completed the picture. 
It seized the side of my bed, shook it with fearful 
strength, and said: Thou shalt not remain here long. 
Upon that I awoke terribly frightened, spra.ng out of 
my bed, ran to the cloister, and cast myself before the 
altar, where I remained for a long time petrified with 
fright." ' Guibert de Noigent relates: '^ One night I 
was awakened by difficulty of breathing; I believe it 
was winter. I lay in my bed and considered myself 
safe in the glow of a brightly burning lamp. Sud- 
denly the deep stillness seemed to be broken by a 
myriad of voices proceeding from above. At the 
same time my head seemed to be wrapped, as it were, 
in a dream; I lost the use of my senses and thought I 
saw a certain dead person appear before me, and a 
' Op. cit., p. 127. 



212 HEADACHE AND NEURALGIA. 

loud voice declared that he had been murdered in his 
bath. Frightened by this apparition, I sprang from 
my resting place with a loud cry, the lamp was extin- 
guished, and in the midst of the horrible darkaess I 
saw the demon in his true form standing by the 
bed," 

In our own day the substance of dreams is some- 
what less demoniacal in character; and witches, devils 
and hags have given place to the denizens of the jun- 
gle and the forest. Tigers, boa constrictors, scorpions, 
centipedes, all the fear-inspiring shapes which adorn 
the pages of a hideous zoology, are the companions of 
tlie modern dreamer. But the repertory of dismal 
shapes is by no means confined to natural history. 
Theology, history, romantic Hterature, love and hate, all 
afford material for dreams. Sometimes those afflicted 
with nightmare experience a sensation as though the 
chest were bound down with chains, or as though a 
huge stone were rolled upon the breast. All such 
sensations are the outgrowth of the disturbances of 
respiration to which reference has already been made. 
Since nightmare usually occurs shortly after midnight, 
Prout is led to the conclusion, that the cause of this 
form of dreaming is to be ascribed to the condition of 
the blood, which at that time according to his observa- 
tions is saturated with carbonic acid to a maximum 
degree. Macnish found that he was attacked by 
nightmare when he sat in an arm-chair or when his 
head reclined upon the table, or even when lying upon 
his side. ' Such a position as the one first described is 
well calculated to cause interference with the freedom 
of the inspiratory act; and thus an undue accumula- 
tion of carbonic acid in the blood is the inevitable 

' Der Schlaf in Allen seinen Gestalten, (translated from the 
English) Leipzig, 1835, 



CONSIDERATIONS ON DREAMS. 213 

result. J. Bonier' has shown experimentally, that 
interference with the ingress and egress of air to and 
from the air passages may result in the production of 
the phenomena of nightmare. In order to prove this 
he fastened the bedclothes over the mouth and nose of 
a person in deep slumber, so that respiration was par- 
tially interrupted. Upon this it was observed that the 
face of the sleeper became suffused and his respiration 
retarded; while the respiratory muscles were thrown 
into violent action and the veins of the neck became 
gi'eatly swollen. After awaking the person experi- 
mented upon related that he had suffered from the 
symptoms of nightmare, the apparition appearing in 
the form of an ugly monster. Severe catarrhal affec- 
tions, when coupled with a somewhat heavy evening 
meal, may give rise to difficulty of respiration and 
morbid dreams, if we are to accept the testimony of 
Binz.' 

But dreams are by no means always characterized 
by the pressure of the terrible or hateful. On the con- 
trary they present not only the shadows, but also the 
brightest side of real and imaginary existence. Only 
in dreams do the majority of mankind ever succeed in 
realizing their most fondly cherished wishes, their 
highest ideals. Many a talent, many a genius con- 
demned by the relentless circumstance of environment 
from adequate expression, has found in dreams a 
temporary emancipation from the thraldom of reality. 
Eiches, power, perfect health, achievementj are all pos- 
sible in dreams, and only thus are the majority of man- 
kind ever to know them. If dreams were invariably 
the outgrowth of impressions and ideas originating in 

^Das Alpdriicken, seine Begriindung und Verhtitung-Wiirz- 
burg, 1855. 
2 Cited by Rhadestock, Op. cit., p. 130. 



214 HEADACHE AND NEURALGIA. 

the occupations of the previous day, then, indeed our 
nocturnal reveries would be far from agreeable. The 
circumstances, however, are fortunately very different. 
It is a matter of experience, in fact, that dreams are 
often built up of remote ideas, the very remembrance 
of which has long since faded from memory. The 
resuscitation of these dim ideas from the lower strata 
of consciousness, as a consequence of central stimula- 
tion, is certainly one of the marvels of psychology. 
Moreover, owing to a further automatic excitation, the 
reproduced ideas are interwoven with other revived 
impressions, so that the dream receives the most varie- 
gated coloring. 



CHAPTER XXXII. 

THE DIFFERENCE BETWEEN DREAMS AND 
AVAKING THOUGHT. 

From what has ah^eady been said with regard to the 
constitution of dreams, it will be seen that a scientific 
classification of the phenomena is beset with unusual 
difficulty. So manifold, and, at the same time, so 
devoid of all sequence and coherence are the manifes- 
tations of dreams, that the comparison of the latter 
with insanity seems in a certain sense justifiable. 

Pfaff, Krauss, Artemidoros, Purkinje, Spitta and 
Nicol have sought to classify the phenomena of 
dreams; but, with the exception of the subdivisions of 
Spitta, these systems possess little practical value. 

The most rational method of approaching the sub- 
ject is that which is based upon a consideration of the 
elements of dreams, and the laws governing the asso- 
ciation of ideas. 

A glance at the composition of dreams reveals the 
fact that ths distinguishing feature of individual con- 
ceptions is their great exaggeration and vividness, 
which is doubtless attributable to the inordinate excit- 
ability of the higher centres. Comparatively insignifi- 
cant impressions transmitted through the centripetal 
nerves are sufficient to arouse a series of the most ex- 
aggerated conceptions. The crackling of a dry floor 
becomes the tramp of the assassin, the moonbeams 
falling upon the eyelids are magni ffed to the dignity of 
a conflagration; while the rusthng of leaves or the 



216 HEADACHE AND NEURALGIA. 

gentle sighing of the wind becomes the roaring of a 
tornado. An insignificant irritation, such as the bite 
of a mosquito, gives rise to a positive sensation of 
pain, and a shght tickUng sensation in the throat 
causes a feehng of suffocation. 

It is a noteworthy circumstance, and one difficult of 
explanation, that the exaggerated conceptions and 
emotions of dreams are far less liable to result in seri- 
ous detriment to the organism than the corresponding 
perturbations of the waking condition. Thus sudden 
and violent grief during waking has frequently re- 
sulted in immediate death; and even imexpected emo- 
tions of intense pleasure have been known to result 
fatally. A soldier returning from the battle -field is 
suddenl}^ apprised of the death of his mother; and 
although inured to the hardships and terrors of the 
campaign, is unable to withstrmd the effects of the 
sudden mental contest, and falls dead, as though smit- 
ten by one of his own bullets. A poor laborer, accus- 
tomed to severe toil, is informed that a relative, of 
whose very existence he was perhaps unaware, has 
died and bequeathed to him a competency, which will 
render him independent for the remainder of his days. 
Instead of manifesting joy he becomes insane or dies. 
The examples are legion. Earely, however, are simi- 
lar effects witnessed even after the most severe attacks 
of nightmare. 

Although we are unable, by a mere fiat of the wiU, 
to cause a cessation of our concej^tions, we are yet able 
to control, within certain limits, the direction of our 
thoughts. What is possible in the waking condition, 
however, becomes impossible for the erratic cerebra- 
tion of sleep. The conceptions arisiug during dreams 
admit of no guidance; the only governing influence 
being the law of the mutual relation of ideas. As a 



DREAMS AND WAKING THOUGHT. 217 

matter of fact, however, the impressions received be- 
fore retiring, as well as the focalization of the thoughts 
in a certain direction for a protracted period of time 
generally have a marked influence upon the con] posi- 
tion of the dreams ol the individual. 

Thus the financier whose mind has long been occu- 
pied with apprehensive speculations, will naturally 
dream of accounts, dollars and cents, and compound 
interest; whereas the captain of a ship is more liable to 
be troubled by nocturnal visions of sea-serpents and 
shipwreck. It will thus be seen that, although we can 
exercise no volitional effect upon the composition of 
our dreams, in the sense that we give direction to our 
waking thoughts; we may, nevertheless, by throwing 
the energies of the mind in a given direction, before 
retiring exert a predetermining influence upon the 
character of our nocturnal reveries. 

I have been thus explicit, as the subject is an impor- 
tant one from a therapeutic standpoint. 

The rapid evolution of conceptions during dreams is 
favorable to the development of new psychological 
combinations. This fact explains the frequent, but, 
at first sight, inexplicable circumstance of a high order 
of rhythmical intellection occurring during dreams. 
Poems, musical compositions, and philosophic epi- 
grams have been compared, and even complicated in- 
ventions conceived during dreams. As a rule, how- 
ever, these nocturnal achievements cannot stand the 
test of daylight; and even the most superficial logic 
serves to reveal their extravagance and worthless- 
ness. The capacit}^ for forming correct inferences 
and judgments is, in fact, greatly reduced during 
dreams, owing to the volatile nature of the concep- 
tions. 

The feeHng of personality, the ''I," is the result of 



218 HEADACHE AND NEURALGIA. 

a summation of all the psychical activities, feelings, 
volitional activity, etc. In the construction of the *' I " 
two factors are principally concerned. First, the 
permanent conceptions formed by ourselves, and 
which are the outgrowth of our motor and "general" 
sensations, and of the memories (and their associa- 
tions) resulting from the repetition of external impres- 
sions. Secondly, the attention or active apperception. 
Now, since in dreams the last named factor of the 
''I" assumes a passive form, the reunion of various 
groups of conceptions under one uniform head is inter- 
fered with, by reason of the chaotic perception and 
remembrance of fragmentary portions of the former 
(the conceptions).' As a consequence of the dimin- 
ished attention, then, the feehng of individuality, the 
sensation of the "I." which is so characteristic a fea- 
ture of the waking condition, is in dreams reduced to 
the last degree. 

The foregoing are the more important points of dif- 
ference between the psychology of dreams and that of 
the waking condition. 

If, in treating the subject somewhat in extenso^ I 
have rendered myself liable to the charge of undue 
prolixity, I can only plead in extenuation the great im- 
portance of the subject to a true understanding of both 
the pathology and therapeutics of sleep. 

It is precisely pain, in its various manifestations, 
which serves quite as much as psychical difficulties to 
cause derangements of sleep. To deal successfully, 
therefore, with these painful conditions, one must 
have a thorough understanding of sleep and its de- 
rangements. 

* Rhadestock, Op. cit., p. 157. 



CHAPTER XXXIIL 

MOEBID SOMNOLENCE. 

In the previous portion of this discussion we have 
described at some length the various conditions which 
tend to reduce the amount of sleep normally required 
by the organism. It now remains to consider briefly 
that condition in which the duration of the sleeping 
period is abnormally increased. 

Any one who has paid special attention to the mat- 
ter, will be able to recall the cases of individuals who, 
by reason of long sleeping or on account of a general 
drowsy habit, have become known to their acquain- 
tances as lazy, thriftless members of society. And yet, 
such persons are frequently far more deserving of 
compassion than of censure; for a closer insight re- 
veals the fact that their inactivity is neither the result 
of defective ambition nor feeble volition, but is rather 
the outgrowth of morbid physiological conditions 
wholly beyond their control. 

Here is an illustration in point : A lady, for whose 
intelligence and Christian character I entertain the 
highest respect, consulted me some time since with re- 
gard to her husband, a man who, up to within a com- 
paratively recent period, had been exceptionally active 
in business. Of late, however, he had become '' ab- 
sent " in mamier, and had besides developed habits of 
extraordinary lethargy. In former times he was in 
the habit of retiring about eleven o'clock ; now he 
sought his bed at nine, where he remained until 



S20 HEADACHE AND NEURALGIA. 

eleven or twelve o'clock the next morning. Instead 
of exhibiting his former vivacity, he remained dur- 
ing this brief period of wakefuhiess, if wakefuhiess it 
could be called, in a condition of apathy, hke one over- 
come with fatigue and about to fall asleep at any 
moment. 

Such conditions as this are doubtless familiar to 
most physicians who have devoted special attention to 
the physiological questions pertaining to sleep. 

The following classical cases, reported by Eobert 
Macnish, are extreme illustrations of morbid somno- 
lence : 

"The case of EHzabeth Perkins is remarkable. 
In the year 1788, she feU into a profound slumber, 
from which nothing could arouse her, and remained 
in this state for between eleven and twelve days, when 
she awoke of her own accord, to the great joy of her 
relatives, and wonder of the neighborhood. On re- 
covering she went about her usual business; but this 
was only for a short period, for in a week after she 
relapsed again into a sleep which lasted some days. 
She continued, with occasional intervals of wakeful- 
ness, in a dozing state for several months. ' ' 

''The case of Elizabeth Armitage of Woodhouse, 
near Leeds, may also be mentioned. The age of this 
person was sixty-nine years. She had been for several 
months in a declinej during which she had taken very 
little sustenance, when she fell into a state of lethargic 
stupor, on the morning of the 1st of July, 1827, in 
which condition she remained, without uttering one 
word, receiving any food, or showing any signs of life, 
except breathing, which was at times almost imper- 
ceptible. In this state she continued for eight days, 
when she expired without a groan." 

One of the most extraordinary instances of excessive 



MORBID SOMNOLENCE. . 221 

sleep, is that of the lady of Nismes, published in 1777, 
ill the " Memoirs of the Eoyal Academy of Sciences of 
Berlin." ''.Her attacks of sleep took place periodi- 
cally at sunrise and about noon. The first continued 
till within a short time of the accession of the second, 
and the second till between seven and eight in the 
evening, when she awoke, and continued so till the 
next sunrise. The most extraordinary fact connected 
with this case is, that the first attack commenced 
always at daybreak, whatever might be the season of 
the year, and the other always immediately after 
twelve o'clock. During the brief interval of wakeful- 
ness, which ensued shortly after noon, she took a little 
broth, which she had only time to do, when the second 
attack returned upon her, and kept her asleep till the 
evening. Her sleep was remarkably profound, and 
had all the characters of complete insensibility, with 
tlie exception of a feeble respiration, and a weak but 
regular movement of the pulse. The most singular 
fact connected Avith her remains to be mentioned. 
When the disorder had lasted six months, and then 
ceased, she had an interval of perfect health for the 
same length of time. When it lasted one year, the 
subsequent interval was of equal duration. The af- 
fection at last wore gradually away; and she lived 
entirely free of it for many years after. She died in 
the eighty-first year of her age, of dropsy, a complaint 
which had no connection with her preceding disorder." 
Of the pathology of these strange cases we know 
nothing; nor can we form an estimate of their causa- 
tion. The most that we can say is that in certain 
cases of extreme exhaustion or intoxication (due to 
renal difficulty, etc.), certain somewhat analogous con- 
ditions may be provoked. The comparison is at most, 
however, but a crude one. 



CHAPTER XXXIV. 

SOME GENERAL OBSERVATIONS ON THE TREAT- 
MENT OF INSOMNIA. 

We have already had occasion tx) refer to the im- 
portant relations existing between derangements of 
the function of sleep and mental disorders. But not 
only has it been shown that sleeplessness is one of the 
concomitants of insanity; for, we have also seen that 
it is an important factor of most painful maladies, and 
particularly of that variety of pain which is traceable 
either to morbid conditions within the skull or such as 
are located outside of it. 

Facts of this kind point clearly enough to the im- 
portance of possessing some knowledge regarding this 
matter of sleep; indeed it is quite inconceivable that 
one should be able to do much for the painful affec- 
tions which we have been considering without such 
knowledge. I shall, therefore, offer no apology for 
recording a few of the more important principles 
underlying the treatment of insomnia. 

In the first place, then, when we are confronted 
with some one of the painful conditions described in 
previous portions of this work, we should at once 
make a careful investigation into the habits, bodily 
condition, and possible hereditary influences of our 
patient. 

If we find that he is a night -worker of long stand- 
ing, we should attempt to gradually abate the vicious 
habit; should we find that the patient has formerly 



THE TREATMENT OF INSOMNIA. 223 

been of a robust habit, and has suddenly or even 
gradually lost flesh, inquiry should immediately be 
made as to the existence of some form of excess or 
wasting disorder, so that we may put a stop to the 
one and address our skill to the amelioration of the 
other. 

Should, on the other hand, a history of syphilis or 
scrofula be forthcoming, we shall at once know what 
we have to do, if we aspire to achieve fundamental 
results. 

There is nothing in these painful conditions more 
significant than a sudden variation in the weight or 
circulatory conditions of the patient. For example, 
we are called to see a young married woman suffering 
from some form of head-pain. Her complexion is 
pale and sallow; she complains of sleeping poorly; she 
has had a miscarriage, or it may be that she has suf- 
fered from leucorrhoea or catarrh of the cervix. 

In such a case as this there are two conditions which 
strike us at once— loss of weight and small, compressi- 
ble pulse. Where this duo exists, more particularly if 
the subject be of neurotic temperament, we are certain 
to have an exacerbation of some form of head pain 
with its baneful accompaniment, sleeplessness. 

Take the exactly opposite condition of a man who 
has gained flesh rapidly. In a considerable proportion 
of such cases the history of alcoholic excesses, with 
its accompanying stasis of the cerebral blood stream, is 
forthcoming. At the same time we learn that the 
patient is a sufferer from cerebral hyperaemia, with 
its consequent symptoms of irritability, depression, 
vertigo, headache and insomnia. Here are two dia- 
metrically opposed conditions. In the case of the 
woman we have general anaemia, with consequent 
impoverishment of the entire nervous system; in the 



224 HEADACHE AND NEURALGIA. 

man we have engorgement, passive expansion of the 
cerebral capillaries with consequent tui'gescence of the 
cerebral circulation. 

To treat these two cases in a similar manner, to pin 
our faith exclusively to mere sedation by chemicals, 
would be simply to ignore the appositeness of the 
physiological circumstances with which we have to 
deal. And yet, these are precisely the things which 
are most systematically ignored; indeed one may say, 
that ninety-nine cases of headache with insomnia are 
attacked through the medium of the apothecary's 
shop, without any regard whatever to special hygienic 
indications. 

Under the special headings of anaemic and hyperae- 
mic headache, I have already discussed the means to 
be resorted to for the relief of the circulatory derange- 
ments, which play such an important part in the two 
affections. All that I then said regarding the appli- 
cability of baths, both warm and cold, as well as what 
was stated regarding the Russian and Turkish baths, 
applies with equal force to the treatment of the anae- 
mic and hyperaemic varieties of insomnia. To repeat, in 
detail, what was then said, would be but a repetition of 
what has already been thoroughly discussed; I would 
therefore merely observe that the two principles to be 
borne in mind in the treatment of these cases of 
insomnia with circulatory disturbances, are first of all 
to correct the latter by appropriate means, and 
secondly, while so doing, to address our efforts to 
calming the irritated cerebral protoplasm. The second 
part of the problem is best accomplished by the use of 
chemical substances, which, having an affinity for the 
cerebral substance, tend by uniting with it to interfere 
to some extent with that metamorphosis which is 
essential to function. Such chemical substances are 



THE TREATMENT OF INSOMNIA. ^25 

the so-called narcotics and sedatives, of which more or 
less has already been said in earlier portions of this 
work. But, while it would, therefore, be a work of 
supererogation to enter again into details regarding 
these substances, I desire to give a general hint or two 
respecting their employment, in connection with in- 
somnia. 

To begin then with the bromides, that group of 
substances so important in the treatment of nervous 
affections of a functional character, I would observe 
that these remedies should be employed with a view 
to exerting a gradual sedative action upon the central 
nervous system, so that a predisposition to slumber 
may be induced. They should therefore be given 
during the day, and preferably during the latter portion 
of it, their administration being in fact continued until 
shortly before the patient betakes himself to bed. A 
moderate dose of chloral, or the tincture of hyoscya- 
mus, or both combined, as in the preparation known 
as bromidia, may then be given, so as to materially 
augment, at the critical moment, the drowsy predis- 
position. 

We have here the key to the secret of obtaining 
results in the treatment of insomnia, whether the 
condition be found in conjunction with mental de- 
rangement, or whether it be an accompanying com- 
plication of a painful affection, or, in short, whatever 
the predisposing factors may be. 

But this is not enough. Were we to rest content 
with the chemical treatment of sleeplessness, we should 
be in grievous error; and yet this is precisely what 
is constantly being advocated in print and in the 
lecture-room. We must look deeper; we must go to 
the bottom of the morbid problem, with which we are 
confronted, so that, having recognized it, we may 
15 



226 HEADACHE AND NEURALGIA. 

combat it with all the resources at our disposal. If we 
have to do with pain- provoking conditions we must 
remove them; if we are confronted with inordinate 
worry we must combat it by the aid of substitution; 
if, finally, we have to do with some morbid condition 
of the organs, resident I care not where, it must be 
met with all the resources at our command. In this 
connection, what has been said regarding secondary 
insomnia may be recalled with advantage. Above all 
things let us eschew inordinate drugging, especially 
before putting our patient to bed. I have protested 
against this custom and shah continue to protest 
against it, as long as I am witness of such flagrant 
abuses of sedative substances both in and out of 
asylums. 

And again, let us not show undue readiness to lay 
hold of the resources of the drug-shop; rather let us 
not forget that, in the ordinary ahments of plain every- 
day life, much is contained which may jjrove useful to 
us. I will merely recall in this connection the hop 
preparations— those ales, stouts, malt hop toniques and 
beers of German make, which in themselves constitute 
an armamentarium somniferum. 

Again, let us but direct our attention to the diges- 
tive organs; what possibilities are here ! So commonly 
are digestive disorders either the immediate cause, 
or, at least, the perj^etuating factor of these derange- 
ments of sleep, that, without a thorough understand- 
ing of the stomach in health and disease, we should 
be quite unable to cope with the secondary conse- 
quences, involving the nervous centres. 

Of electricity, baths, and cognate adjuncts in treat- 
ment, a sufficiently extended mention has already been 
made in the earlier portions of the work. I shall, there- 
fore, close this discussion of the various questions per- 



THE TREATMENT OF INSOMNIA. 227 

tainiiig to normal and morbid sleep by observing, once 
again, that the subject is of the first importance to a 
correct understanding and management of the painful 
affections which we have been considering, and more 
particularly of those pains, located in and about the 
head, which constitute such prolific sources of human 
unhappiness. 



CHAPTEE XXXV. 

THE LOCALIZATION OF THE ACTION OF REMEDIES UPON 
THE BRAIN. — ADMINISTRATION OF CHEMICALS 
AYHICH ACT IN SMALL DOSES, BY THE NOSE ; THOSE 
AVHICH MUST BE GIVEN IN LARGER AMOUNTS TO 
PRODUCE THEIR EFFECTS, BY THE MOUTH. — COM- 
PRESSION OF THE INTERNAL JUGULARS. 

In the previous portions of this work, we have de- 
voted considerable space to the consideration of the 
various theoretical and technical questions pertaining 
to the local use of remedies in neuralgia. And let 
me say, that the prominence accorded this portion of 
the subject is not merely a question of individual pre- 
dilection, but rather of indisputable expediency, justi- 
fied as it is by what we know of neuritis as well as by 
the practical results obtainable in the clinic. Indeed, 
so apparent are the advantages derivable from the lo- 
calization of remedies in the treatment of painful affec- 
tions due to inflammatory or other changes of the 
peripheral nerves, that I have long desired to extend 
the principle to the central nervous system, and more 
especially to the brain. For it will occur to any medi- 
cal man of average perspicuity that the solution of 
this problem must render material assistance in the 
management of various functional difficulties of in- 
tracranial origin, not the least of which are certain 
idiopathic varieties of headache and insomnia. It 



THE ACTION OF REMEDIES UPON THE BRAIN. 220 

may as well be admitted, however, at the very thresh- 
old of these reflections, that the concentration of the 
effects of chemical solutions upon the internal organs 
is beset with difficulties, insurmountable ones too, in 
many instances. Thus one reads in the journals 
from time to time accounts of injections of medicinal 
fluids into the parenchyma of the lung, or other im- 
portant viscus, but the thought at once occurs that 
these fluids can at best produce but evanescent effects 
upon neighboring morbid products; for they — the 
fluids — are soon carried away to distant parts of the 
organism by the circulation ; and being thus dissipated, 
their local remedial effects are proportionately attenu- 
ated. 

There is, however, one organ which is exceptionally 
well placed with respect to the possibility of concen- 
trating the action of remedies upon it ; I refer to the 
brain, and more especially to the cortical layers of the 
cerebrum. 

To appreciate how true this is, it is necessary to 
place in juxtaposition the following facts : 

1. That the main blood -supply of the cortex is con- 
tingent, or largely contingent, upon the unobstructed 
flow through the carotid and jugular vessels. Hence, 
when the blood flow in one or both of these sets of 
vessels is arrested, or even partially arrested, as by 
compression, cortical function is directly interfered 
with, as is shown by the confusion of ideas, stupor, 
and even unconsciousness engendered. 

2. It has long been known — and the fact has fre- 
quently been commented upon in medical literature — 
that chemicals applied, especially in a fluid state, to 
the lining membrane of the nasal cavity are speedily 



230 HEADACHE AND NEURALGIA. 

absorbed, producing in this way characteristic physio- 
logical effects. Thus calomel has been blown into 
the nose, producing in a short time severe salivation.' 

Narcotic substances, and more especially morphine 
and cocaine, have also been spread upon the mucous 
membrane of the nasal cavity, giving rise in a short 
time to characteristic phenomena. I am told that the 
effects thus induced upon the central nervous system, 
and more especially the brain, by the use of the last- 
named drug are familiar to rhinologists. 

The most reasonable and generally accepted explan- 
ation of the prompt action of narcotic substances when 
used in this way is that which assumes that the ab- 
sorption of the remedy — or at least the greater part 
of it — takes place by the way of the vessels which 
penetrate the lamina cribrosa. If we admit the 
plausibility of this hypothesis, we shall then perceive 
that remedies administered b}^ way of the mucous 
membrane of the nose must reach the brain, and 
especially the cortex cerebri, in a more concentrated 
state than when administered at a distance, either 
hypodermically, per rectum, or by the stomach. Even 
though the amount of medicinal substance absorbed 
be not great, its increased concentration at the seat of 
influence (the brain) must of necessity result in physi- 
ological effects out of proportion to the quantity of 
chemical administered. 

Here we have an explanation, and I think a true 
one, of the remarkable cerebral symptoms often pro- 

' De rAdministration des Medicaments par rintermediaire de la 
Muqueuse des Fosses nasales ; par Rainbert, Journal de Medecine 
de Chirurgie et de Pharmacologie, Bruxelles, 1867, vol. xlv. , p. 17, 
seventh line from top of page. 



THE ACTION OP REMEDIES UPON THE BRAIN. 231 

duced by exceedingly small quantities of medicinal 
substances when applied in solution to the eye and 
conjunctiva. 

3. It is a fact that, if narcotic fluids be introduced 
into the nasal cavity in the manner previously set 
forth, and if shortly thereafter the flow of blood in 
the jugular veins be considerably retarded by the ap- 
plication of pressure at a suitable point in the neck, 
the effects of the remedies thus administered may be 
appreciably enhanced and prolonged. This accords 
with all that I have been able to ascertain respecting 
the behavior of remedies when brought in contact 
with the peripheral nerves, by hypodermic injection, 
and maintained there by occlusion of the capillaries, 
or by constriction of the artery, veins, or both, above 
the point of injection (next the heart). These pre- 
liminary observations will, I trust, make the principles 
involved abundantly clear to any physician of average 
intelligence. Let me pass, then, at once, to the de- 
scription of the simple procedure which I have found 
most serviceable in giving practical effect to the prin- 
ciples above enunciated. ' The first step of importance 
is the introduction of the remedy by way of the nose. 
To do this most effectually the mucous membrane 
should first be cleansed with warm water, the latter 
serving at the same time to expand the capillaries. 
The medicament (morphine, cocaine, atropine, etc.) 
may then be introduced in solution through the nos- 
trils by the aid of an ordinary medicine dropper or 
atomizer. This simple manipulation is best accom- 
plished while the patient reclines upon his back. 

After the lapse of ten or fifteen minutes the second 

1 Vide the "Medical Record " of December 31st, 1893. 



232 



HEADACHE AND NEURALGIA. 



step may be proceeded with. This consists in materi- 
ally restricting the lumen of the internal jugular 
veins by the application of pressure. 

After numerous trials, I have found that the jugu- 
lars are best compressed by the application of small 
dry cups over the course of the vessels, one at each 




Fig. 16. 



side of the neck on a level with — or a little below the 
level of — the thyroid cartilage. 

The cups, which are joined together in front by an 
adjustable steel band, are about two inches long and 
half an inch wide ; they are made of metal — silver or 
steel — and are held in place by an elastic strap, which 
passes around the neck and is secured in place behind 
by the aid of a simple buckle (Fig. 16). The open side 
of the cup is, moreover, somewhat concave in au 



THE ACTION OF REMEDIES UPON THE BRAIN. 233 

antero-posterior direction, which admits of elevating 
the veins and surrounding tissues more effectually. In 
this way it is possible to draw the vessels into the 
cups, partially at least, thus causing the edges of the 
latter to act energetically upon the lumen of the veins. 
The little dry cups being maintained in position over 
the vessels by the aid of this simple band, the air con- 
tained in them is rapidly exhausted by means of an 
air-pump and vacuum-chamber, which exert their in- 
fluence upon the interior of the cups through the 
intermediation of small, non -collapsable india-rubber 
tubes (Fig. lY). 

It is self-evident that the cohesion of the compress- 
ing apparatus thus obtained, as well as the elevation 
of the tissues within them, render valuable assistance 
by preventing the slightest displacement of the subja- 
cent vessels. In a word, the veins, instead of being 
compressed in a backward direction, are, as previously 
pointed out, drawn toward and compressed by the 
edges of the cups. When all is properly adjusted, 
the elastic bands previously described may be tight- 
ened at will, thus adding mechanical to atmospheric 
pressure. This last step is usually, however, unneces- 
sary, the atmospheric pressure being adequate. 

When slight vertigo has been induced in this way, 
the evidence is conclusive that the stasis of the intra- 
cranial venous circulation is sufficient for therapeutic 
purposes. 

There is no special limit to the length of time dur- 
ing which compression may be continued ; but from 
what I have been able to determine, I should fancy 
that from twenty minutes to half or three-quarters gf 
an hour are sufficient. 



234 



HEADACHE AND NEURALGIA. 



Illustrative Cases. — The following cases are cited 
with a view to illustrate the facility and rapidity with 
which a variety of disagreeable sensations in. the head, 




including minor degrees of pain and depression, are 
relieved by resort to this simple procedure. 

Mr. A. C was referred to me over three years 



THE ACTION OF REMEDIES UPON THE BRAIN. 2)35 

ago by Dr. C. H. Avery, on account of "severe and 
persistent headache." When I first saw him the 
headache was diffuse in character, continuous, but 
not specially severe. He informed me, however, as I 
find by reference to my case -book, that at times he is 
afflicted by sudden and very severe exacerbations of 
pain ; and that, at such times, the pain is almost en- 
tirely confined to the occipital region. There is very 
little difference between the pain felt at night and 
that experienced during the day. 

There are no ataxic symptoms; the disks of both 
eyes are normal, but the pupils are quite uneven, the 
right one reacting little or not at all to strong light. 
I sent him to Dr. David Webster for an opinion, who 
wrote me that there was undoubted "paresis of the 
right sphincter iridis, without paresis of the ciliary 
muscle." A high degree of hypermetropia was also 
present, for which Dr. Webster prescribed the neces- 
sary glasses, to be worn constantly. Incidentally he 
also expressed the belief, in spite of the absence of a 
specific history, that the mydriasis, and probably also 
the headache, were due to nervous syphilis. 

My own suspicions having taken a like direction, I 
placed him at once upon large doses of the iodide of 
potash, which were gradually increased to the point 
of tolerance. 

After several weeks there was appreciable diminu- 
tion of the pain, so much so that after three months 
his visits were discontinued. A year or two later I 
saw him again, and he stated that he was often free 
from pain for prolonged periods — from several days 
to three or four weeks. 

The paresis of the right sphincter iridis was also 



236 HEADACHE AND NEURALGIA. 

apparently improved, though the contraction 'of the 
pupil was quite sluggish. 

So far as my case-book reveals, I did not see him 
again till October 19th, 1892, when he called at my 
office, complaining of an unusually severe paroxysm, 
the predominantly painful area being located in the 
frontal region. This seemed a good opportunity of 
testing the above method of locating the action of 
remedies upon the intracranial structures. 

Accordingly I placed the patient upon his back, in- 
jected into both nostrils, as high up as possible, several 
drops of a medicated solution, aggregating morphine 
i grain and atropine y^. Ten minutes later, there 
being as yet little diminution of the pain, I compressed 
both jugular veins in the manner previously set forth. 

The relief thus afforded excited the wonder of the 
patient, who declared, after the lapse of five minutes 
from the time of applying the compression to the 
jugulars, that he "felt no pain." 

Later he informed me that the relief thus obtained 
was unusually prolonged, there being little or no pain 
experienced during the entire following week. I 
shall have something to say regarding the subsequent 
history of this interesting case, at some future time. 
My object in citing it on the present occasion is merely 
to show how promptly a relatively severe frontal 
headache was relieved by medication by the nose, 
combined with simultaneous compression of the in- 
ternal jugulars. 

Mrs. E. N. T was referred to me by Dr. Charles 

A. Limeburner for severe, continuous local headache, 
possibly the result of circumscribed chronic menin- 
gitis (?). 



THE ACTION OF REMEDIES UPON THE BRAIN. 237 

Five months ago, while walking in the garden, 
patient stepped upon the prongs of a rake, which had 
been allowed to remain in an upright position, so that 
the handle leant against a wall. The result of this 
action was to cause the implement to fly forward, 
inflicting a blow of such severity upon the left side of 
her head that she fell to the ground in a state of 
partial or total unconsciousness. 

On regaining consciousness, she felt nothing more 
than the soreness which might naturally have been 
anticipated from the violence of the contusion. In a 
few days, however, quite severe pain set in, the pain- 
ful sensations being deep-seated and corresponding 
quite accurately with the area of traumatism, i.e., 
the left parietal region. 

As the pain was not relieved by extracranial meas- 
ures, and as the various coal-tar derivatives did not 
seem to help her much, or, at all events, but slowly, 
I decided to endeavor to act more directly upon the 
intracranial structures by invoking the method of 
medicinal localization previously described. 

Accordingly, while the patient lay on her back, I 
sprayed into her nostrils morphine, gr. -J; atropine, 
gr. 2-J-o. Ten minutes thereafter, patient experiencing 
little relief, I applied the pneumatic compressor over 
the jugular veins, with the result that, within five or 
six minutes from the moment of its adjustment, there 
was complete cessation of pain. Here, again, we 
have conclusive proof of the increased physiological 
potency of medicinal solutions, when they (the solu- 
tions) are made to linger in the tissues of the brain or 
other portion of the central nervous system by the aid 
of artificially induced stasis or partial stasis in the 



238 HEADACHE AND NEURALGIA. 

capillaries. Such stasis may be induced in three ways 
— and I have tried them all — first, by compressing the 
carotids; secondly, by compressing the jugulars; and 
lastly, by compressing both, the arteries and veins. 
Compression of the jugulars with the least possible 
interference with the circulation in the carotids, will 
alone be discussed on this occasion. 

Compression of the jugulars by the aid of the pneu- 
matic compressor, as here described, is not difficult, 
especially when the patient reclines in a dorsal posi- 
tion, the head being thrown slightly backward so as 
to place the vessels slightly on the stretch. This pro- 
cedure may be invoked without hesitation in the 
treatment of individuals under forty years of age. 

In elderly persons, on the contrary, where an athe- 
romatous condition of the cerebral blood-vessels is 
among the possibilities, it will be well either to aban- 
don this mode of treatment, or to compress both arteries 
(carotids) and veins (jugulars) at once, thus avoiding 
an increase in intra -arterial pressure and consequent 
danger of rupture and hemorrhage. 

Mr. V. N , also kindly referred to me by Dr. 

Charles A. Limeburner, has suffered for several 
months from what • Dr. Limeburner believes, and 
rightly, I think, to be neurasthenic headache. 

The chief complaint of this gentleman is that he is 
beset by a sensation of heaviness in the head, more or 
less continuous, and frequently coupled with dull pain 
at the vertex and profound depression. In addition 
to these symptoms, he also evinces dread of respon- 
sibility and society, loss of memory, especially for 
recent events, inability to concentrate his attention 
for any length of time without discomfort; and, in 



THE ACTION OF REMEDIES UPON THE BRAIN. 239 

short, he affords a typical illustration of the classical 
form of cerebral neurasthenia. 

With a view to at once gain his confidence by re- 
lieving his head symptoms — the vertical pain, the 
heaviness, and the depression — I jDroceeded to invoke 
once more the aid of medicinal localization. 

Instilling into the nasal cavity a few drops of water 
containing atropine, y^-g-, and cocaine, gr. J, I applied 
the pneumatic compressor, as already so frequently 
described. After the lapse of five or six minutes 
there was a decided feeling of relief, and in ten or 
twelve minutes the disagreeable head symptoms had 
entirely disappeared. The relief in this case was 
complete during the following five or six days, when 
the procedure was again repeated, with the same re- 
sults. As a matter of course, various measures di- 
rected to the removal of the exciting cause were 
employed in this as in all similar cases, but as they 
have no bearing on the point at issue, and involve, 
moreover, matters which are part of the common 
knowledge of the profession, I have made, and shall 
in future make, no detailed reference to them. As a 
matter of theoretic interest, I may observe that, after 
instillation of the atropine and application of compres- 
sion to the jugulars, there was marked dilatation of 
the pupils. 

Mr. J. E. K has been kindly referred to me by 

Dr. Fayette Smith, on account of an obstinate form 
of myalgia. He also suffers from attacks of mental 
hebetude, depression, and headache. During one of 
these seizures, which failed to yield to either salol and 
phenacetine, or antipyrine and ammonia, I instilled 
into his nostrils morphine, gr. |-, atropine, gr. y^^-, 



S40 HEADACHE AND NEURALGIA. 

and hyoscine hydrobrom., gr. -^^-q, and shortly there- 
after applied the pneumatic compressor to the jugulars. 

As a result all the disagreeable symi)toms disap- 
peared within ten or fifteen minutes, much to the 
delight and astonishment of the patient, who had 
hitherto failed to obtain relief from several remedies 
administered in the conventional manner. 

Mr. L. E has been referred to me by Dr. David 

Webster, on account of paralysis of the third nerve, 
with concomitant headache, both phenomena being 
doubtless specific in origin. Dr. Webster has already 
obtained some amelioration by the administration of 
the iodide of potash combined with inunctions of the 
oleate of mercury. As, however, there is still con- 
siderable diplopia, Dr. Webster feels that local appli- 
cations of electricity should be tried. Accordingly, I 
have made such applications (of faradism) as near the 
vicinity of the affected muscles (left internal and in- 
ferior rectus) as possible, employing for the purpose a 
delicate conical sponge electrode. 

The benefit accruing from this phase of treatment 
has been rapid, the double vision having quite disap- 
peared after the third application. I may add, in 
this connection, that the eye was thoroughly cocain- 
ized before applying the electrode, the lids being held 
apart by an ordinary eye -speculum. 

And this brings us to the point of special interest 
in connection with the present argument. As has 
already been said, this patient was a sufferer from 
headache of a persistent, dull character, culminating, 
at times, in exacerbations of considerable severity. 

At my request he called at the office during one of 
these attacks, and I proceeded at once to attempt to 



THE ACTION OF REMEDIES UPON THE BRAIN. 241 

abolish the painful symptoms. Spraying the nasal 
cavity with an aqueous solution of morphine, gr. -J-; 
cocaine, gr. i; and hyoscyaminse sulphas, gr. y-Jir^ I 
had the patient remain in a recumbent position for 
ten or fifteen minutes. At the end of this time, he 
stated that he felt "somewhat better;" but, as the 
relief was not complete, I at once applied the pneu- 
matic compressor to the jugulars, when the patient 
almost immediately declared that all pain had van- 
ished. 

Mrs. C. L. V was referred to me by the late 

Dr. James E. Leaming, on account of persistent in- 
somnia, accompanied by attacks of dull, clawing pain 
at the vertex. As the patient was much debilitated, 
and as changes in position — and notably lying down 
and suddenly sitting up — had a perceptible effect upon 
the character of the pain, I concluded that circulatory 
anomalies, probably anaemia, had something to do 
with its genesis. Accordingly, I applied the com- 
pressor to the jugulars, with the result that consider- 
able relief was at once afforded. This improvement 
was, however, evanescent ; for, on removal of . the 
compressor, it shortly returned. 

I then proceeded as in the previous case, instilling 
at first the analgesics and sedatives into the nasal 
cavity, and then applying the compression to the 
jugulars. Precisely the same results were obtained 
as in the previous case — relief from pain, lasting 
several hours. 

This case is interesting, as it affords incontestable 
proof of the superiority of jugular compression com- 
bined with intranasal medication over jugular com- 
pression alone. 
16 



242 HEADACHE AND NEURALGIA. 

Mr. G. F was referred to me several years ago 

by the late Dr. Cornelius R. Agnew, on account of 
spinal neurasthenia, accompanied by impairment of 
sexual vigor and insomnia. For several years patient 
had been harassed by imperative craving for alcoholic 
stimulants, the morbid desire occurring periodically, 
twice or thrice yearly. The excesses which resulted 
from these impulses always left the patient tremulous 
and greatly prostrated, and eventually he became a 
victim of obstinate and constantly recurring headaches, 
in addition to the symptoms which had more espe- 
cially attracted Dr. Agnew 's attention. The eye con- 
ditions bore no special relation to the case, consisting 
as they did in a minor degree of hypermetropia and 
conjunctivitis. Appropriate glasses had corrected the 
first, and a simple eye-wash the second element, so 
that when he arrived at my ofQce the nervous phe- 
nomena were the predominant, and indeed the only, 
feature. These I was able to abate by a course of 
treatment of reasonable length ; but I was not able to 
overcome the patient's imperative impulses to periodic 
spreeing. 

Thus it happened that, for the last few years, this 
gentleman has been in the habit of seeking me out, 
after one of these debauches, with a view to having 
the results — the head pains, the tremor, the depres- 
sion — eliminated. Recently he called upon me for the 
usual purpose, suffering, as he declared, more than 
on former occasions. Especially annoying was the 
sensation of fulness and pain in the head, which made 
him feel, as he expressed it, "as though he would like 
to jump off the dock." This seemed a good opportu- 
nity to endeavor to relieve the pain by concentrating 



THE ACTION OF REMEDIES UPON THE BRAIN. 243 

the effect of the remedies employed by the aid of 
jugular compression. 

As the patient was a sufferer from an old catarrhal 
difficulty, which had evidently deprived the nasal mu- 
cous membrane of much of its absorbent power, I 
decided to administer the remedies by the mouth. I 
quite realized that in doing this, I was resorting to a 
method inferior to that previously described, when 
judged by rigid physiological standards; for these 
demand the placing of the medicament as near the 
nervous structure to be affected as possible. However, 
I could not help feeling that the retardation of the 
medicated blood in this way would eventuate in some 
enhancement of physiological effect, and the sequel 
proved that the inference was a correct one. 

As a preliminary precaution, the patient was given 
forty drops of the aromatic spirits of ammonia, and 
shortly afterward fifteen grains of antipyrine were 
administered. Though the ammonia, being quickly 
absorbed, induced a considerable increase in the fre- 
quency and vehemence of the heart's action, there 
was no abatement in the head symptoms — the pain, 
hebetude, and depression — even after the lapse of half 
an hour. And yet there was some diaphoresis, show- 
ing that a considerable quantity of the antipyrine had 
been absorbed. 

It was at this juncture that I applied the pneumatic 
compressor to the jugulars in the usual w^ay. 

The phenomena thereby evoked appeared within 
five minutes and were truly remarkable, if credence 
is to be given to the patient's own statements. He 
declared that thB heavy feelings in the head had dis- 
appeared; that he no longer felt pain; that the de- 



244 HEADACHE AND NEURALGIA. 

pression had entirely relinquished its hold upon him ; 
and that, in a word, he was "cured," as he laconically 
expressed it. 

Obviously, the plan of treatment just described has 
distinct advantages; for, when the nasal mucous 
membrane is sufficiently healthy to absorb the medi- 
cament, the stomach, if delicate, may be spared the 
reception of chemical products which might add to 
the local derangement. Powerful alkaloids are those 
best adapted to this form of administration, as they 
may be given in small doses, and are, therefore, 
readily taken up by the nasal mucous membrane, 
whose power of absorption is limited. Again, there 
is little or no danger of setting up a pernicious habit, 
as is the case in hypodermic exhibition. Then, too, 
the prompt relief of intractable symptoms in a rela- 
tively short time, and without inordinate drugging, 
is a notable advantage. Finally, I would add that 
where the nasal mucous membrane is not sufficiently 
healthy to absorb the medicated fluid in sufficient 
quantity it may be injected into or beneath the intra- 
nasal mucous membrane by the aid of a long hypo- 
dermic needle attached to the syringe conventionally 
employed. This I have done on one occasion, only. 



APPENDIX. 



EYE STRAIN 



AS A 



CAUSE OF HEADACHE 



BY 

DAVID WEBSTER, M.D., 

Professor of Ophthalmology in the New York Polyclinic ; Surgeon to the Manhattan 

Eye and Ear Hospital ; Consulting Eye Surgeon to the Skin and Cancer 

Hospital ; to the Hospital for the Ruptured and Crippled, to the 

Hackensack Hospital, to the House of Mercy, 

New York, etc., etc. 



NEW YORK: 

E. B. TREAT, 5 COOPER UNION 

London: H. K. Lewis, 136 Gower St. 

1894 



INTRODUCTORY. 



That headaches are frequently caused by eye-strain 
resulting from various abnormal conditions of the vis- 
ual organs has long been well known to the ophthal- 
mologist, and is beginning to be recognized as a fact 
by the medical profession generally, as well as by the 
laity. A considerable proportion of the practice of 
every ophthalmologist is made up of patients referred 
to him by their family physician, or coming to him of 
their own accord, who are conscious that their head- 
aches are directly traceable to the use of their eyes, and 
who hope to get relief by wearing properly selected 
glasses, or by such other means as the skilled ophthal- 
mologist may suggest. 

Headaches dependent upon inflammatory condi- 
tions of the eyes, or of their appendages, do not come 
within the scope of this paper. We shall confine our 
remarks to those headaches which are dependent upon 

1. Errors of refraction, 

2. Impaired accommodation, and 

3. Insufficiency of the extrinsic ocular muscles. 



CHAPTER I. 

HEADACHES DEPENDENT UPON ERRORS OF REFRACTION. 

It must not be supposed that all persons who have 
errors of refraction are sabject to headaches, or other 
reflex troubles, caused by the same. On the contrary, 
this is true of a very small proportion of such persons. 
The fact is that very few persons are free from refrac- 
tive errors. Probably there are not more than half a 
dozen emmetropic eyes out of every hundred. But 
the great majority of ametropes suffer no especial 
inconvenience from their refractive errors. The fact 
remains, however, that a certain proportion of such 
cases are the victims of headaches, and that nothing 
but the wearing of glasses correcting their ametropia 
will afford them relief. Therefore, in all cases where 
the patient refers his headache to the use of his eyes, 
either for near or for distant vision, he should be care- 
fully examined by a competent ophthalmologist, and 
if ametropia be found it should be duly corrected. 
Indeed, in every case of headache, where aU other 
causes have been excluded, it is weU to have the con- 
dition of the eyes investigated. For it is not uncom- 
mon to find a considerable degree of refractive error, 
entailing a large amount of ciliary strain, where the 
patient does not refer any of his symptoms to his eyes, 
but is inclined to boast of the perfection of those 
organs. The strain is there, nevertheless, but it makes 
itself felt elsewhere. 

The following case illustrates the relief of headache 
by the constant use of glasses correcting a moderate 



250 HEADACHE AND NEURALGIA. 

amount of hypermetropia, or oversight edness, in a 
young person. 

Case L— Feb. 9, 1887.— John E., get. 20, student, 
complains of pain in the eyes after reading, and on 
exposure to bright light. The reflection from snow is 
especially trying. He has, for the last three or four 
weeks suffered from headaches after even moderate 
use of his eyes. 

Visional S ; Hm -^V, both eyes. 

Orthophoiia (physiological equilibrium of ocular 
muscles). 

Abduction 1:° ; adduction 10°. 

Ophthalmoscopic examination shows that the 
media and fundus are normal, 

Feb. IT. — Under atropia, \ = |J with + ^, both 
eyes. Abduction 5° ; adduction 13°. 

Feb. 26. — Ordered spectacles + 3V for constant use. 

Jan. 26, 1889. — Mr. E. returns, saying that he wore 
the glasses only about three months, when finding on 
trial that the pain in his eyes and head did not return 
on leaving them off, he discarded them entirely. He 
is now married, and is devoting himself to the study 
of paleontology, involving a great deal of close use of 
the eyes. About a month ago the headaches returned. 
The pain is confined mostly to the frontal region, and 
the attacks occur about twice a week. Each attack 
lasts five or six hours. When the attack comes on he 
goes to bed as soon as possible, and after five or six 
hours' suffering he goes to sleep and "sleeps it off," 
awaking, after some hours of sleep, free from head- 
ache. These attacks are sometimes accompanied with 
nausea, never with vomiting. The severer attacks 
come on after prolonged use of his eyes. The print 
often appears blurred after he has read for a short time. 

Y = f I ; Hm 0.5 D., both eyes. 



ON EYE STRAIN. S5l 

Hyperphoria 0° ; esophoria 2° ; in accommodation, 
none. Abduction 6° ; adduction 14°; sursumduction, 
R. 1° ; L. r. 

No lesion of media or fundus. 

Ordered glasses + 0.75 D. for all the time. 

April 16. — Mr. E. says he has been wearing the 
glasses constantly as ordered, and that he has not had 
more than three attacks of headache in the last three 
months. Two of these attacks were, he feels sure, not 
due to eye-strain, but occurred after imprudence in 
diet. The other attack was one of the old headaches, 
and he had to go to bed and *' sleep it off " as he used 
to do. 

The eyes are so constituted, and are in such rela- 
tion to the nervous centres, that they tuill see as clearly 
as possible, independently of any conscious volition on 
the part of the individual. It is necessary to distinct 
vision that the rays of light proceeding from the object 
seen should be brought to a focus upon the retina. In 
ordinary distant vision, the emmetropic, or normally 
shaped eye accomplishes this without any effort, be- 
cause its antero- posterior diameter bears such a relation 
to its refractive media that parallel rays are brought 
to a focus upon its retina without any effort of adjust- 
ment, that is, with its ciliary muscle in a state of relax- 
ation. But in the hypermetropic eye, which is shorter 
in its antero-posterior diameter than the emmetropic, 
when the ciliary muscle is at rest the focus for parallel 
rays is behind the retina. If it were possible for a 
hypermetrope to go about without keeping up a con- 
stant accommodative effort he would see all objects 
under circles of dispersion, and his distant vision would 
be as indistinct as that of a myope, or near-sighted 
person. This state of things actually exists in all cases 
where the power of accommodation has been lost in 



•25 -2 Headache and keuiialgia. 

hypermetropic eyes, either from old age, or from dis- 
ease, or from the use of mydriatics ; and indeed it is 
always present in very high degrees of hypermetropia, 
the hypermetropia heing so great that the individual 
cannot overcome it by any effort of accommodation. 
The ciliary muscle, failing to increase the focalizing 
power of the crystalline lens sufficiently to secure even 
moderately clear vision, gives it up, so to speak, and 
the eye contents itself with such poor vision as it can 
secure without any effort. It is hardly necessary to 
say that in these cases of hypermetropia, where the 
ciliary muscle remains relaxed, and the alternative of 
blurred vision is accepted, there is no headache, so far 
as the factor that we are now speaking of is concerned. 
But in all moderate, and even considerable, degrees of 
hypermetropia, in young persons, clear vision is con- 
stantly kept up by constantly contracting the ciliary 
muscle. In near work, such as reading, writing, draw- 
ing, sewing and painting, the ciliary muscle of the 
hypermetrope has to do exactly as much work as that 
of the emmetrope, in addition to the work that it has 
to perform constantly when gazing upon distant ob- 
jects. In short, the ciliary muscle of the emmetrope 
is at rest except when he is engaged in 7iear work, 
while that of the hypermetrope is at work always, 
except when his eyes are closed, and does additional 
work while looking at near objects. In consequence 
of this constant and unremitting use the ciliary mus- 
cles of the hypermetrope become increased in size and 
in strength, and thus, in the great majority of cases 
are enabled to bear the additional strain. But if the 
general muscular system chances to be weakened by 
an attack of illness, or if the already overworked cili- 
ary muscle is given additional labor, as in the case of a 
college student preparing for examination, or in the 



ON EYE STRAIN. 253 

case of a person studying any science enthusiastically 
day and night, the result is likely to be headache, which 
can be relieved only by resting the ciliary muscles. 

Thus in the case of the hypermetrope reported 
above, his first breakdown was caused by over-use of 
his eyes at college. He needed the relaxation afforded 
]yy glasses only to bridge him over that period. As 
soon as he was in circumstances to give his ciliary 
muscles a partial rest the glasses were laid aside with 
impunity. When he plunged into work again, involv- 
ing extra use of his eyes, the headaches returned in a 
worse form than before, and he was compelled to 
resume the use of spectacles. 

Case II.— July 1, 1880.— Mrs. Dr. J. J. R., set. 33, 
has all her life been subject to attacks of migraine, but 
the attacks have been more frequent and more severe 
for the last eight or nine years. Although she does 
not complain of her eyes her husband brings her for 
examination in the hope that the headache may be 
found to be due to eye-strain, and that she may get 
that relief, through treatment of her eyes, or through 
spectacles, which all other means have failed to afford. 

R. V = li ; |{f + with + ^V cylindric, axis 90°. 

L. V = 1^ ; IS- - with + ^V cylindric, axis 90°. 

Orthophoria ; exophoria in accommodation 4°. 

Abduction 4°; adduction 14°. 

Ophthalmoscope ; no lesion. 

July 2. — Both eyes under atropia: 

R. V = If + with -f A- s, C + A c, ax. 90°. 

L- V = U + with + h s, C + eV c, ax. 90°. 

July 12. — The patient accepts only the cylindrics, 
rhe glasses which improved her vision before atropia 
was dropped into her eyes. 

Glasses, + i-^ c, ax. 90°, for right eye, and + -J^ c, 
ax. 90°, for left eye, were prescribed for constant use. 



254 HEADACHE AND NEURALGIA. 

January 3, 1887. — Dr. E. says the patient has been 
very much better, but not entirely free from her 
attacks of headache. 

April 26.— The patient states that her attacks of 
headache are reduced at least seventy- five per cent., 
but that for the last two months they have been com- 
ing on more frequently again. The glasses which 
were found to correct the total error of refraction were 
now accepted by the patient, and she was advised to 
wear them instead of the partial correction which she 
had been using. I received a letter from her husband, 
dated Feb. 1, 1889, nearly two years after the last 
glasses were prescribed, in which he stated that she 
had experienced great relief, but that she had recently 
had a partial relapse. I referred him to another oph- 
thalmologist in a distant city to which he had re- 
moved, and have not since heard from the patient. 

The eye-strain which caused the headache in this 
case was due to compound hypermetropic astigma- 
tism. The unequal contraction of the ciliary muscle 
which is necessary to produce a compensatory assym- 
metry of the crystalline lens, and thus to neutralize 
the astigmatism of the cornea and procure as clear 
vision as possible, is, I believe, a prolific source of head- 
ache. As in the case just related, correction of the 
astigmatism alone is often sufficient to afford tempo- 
rary relief. It generally becomes necessary later to 
correct the hyper metropia also. 

Case III.— January 28, 1889.— Sidney G., set. 33, 
bachelor, no occupation, was referred to me by Dr. J. 
Leonard Corning with a letter, saying : '' Mr. G. is a 
sufferer from general anaemia coupled with various 
nervous symptoms, notably exhaustion, vertigo and 
painful sensations in the head. These phenomena are 
pnrticularly pronounced in the morning. The head 
symptoms are often evoked by reading." 



ON EYE STRAIN. 255 

Mr. G. had been under severe emotional strain for 
several years on account of the incurable illness of his 
mother, had kept late hours and had studied hard. 
His attack of nervousness and headache had lasted 
for over six weeks. 

R. V = fl ; Hm 0.50 D. 

L. V = U ; IT with + 0.50 D. cyL, ax. 90°. 

Orthophoria ; exophoria in accommodation, 1°. 

Abduction 6°; adduction 29°; sursumduction R. 1°, 
L. 1°. 

January 30. — Under homatropine: 

R. V = 14} -; ^ with + 0.50 D. cyl., axis 70°. 

L. V = U - ; -H with + 0.75 D. cyl., axis 110^ 

Ophthalmoscopic appearances normal. 

February 1.— The above cylindrical glasses, which 
gave him the best vision while his accommodation was 
suspended by homatropine, being now placed before 
the patient's eyes, in trial frames, were found to be 
comfortable while they sharpened his vision a little. 
They were, therefore, prescribed for constant use. 

February 16. — Mr. Gr. has been wearing the glasses 
constantly since ordered, and expresses himself as 
much relieved by them. Dr. Corning, who kept the 
patient under treatment for some time, assures me 
that the glasses aided him greatly in the restoration of 
Mr. G.'s health, and in the permanent relief of his 
headache. 

Thus we find that the correction of ocular errors, 
while not of itself always sufficient to relieve head 
symptoms, is often an invaluable adjunct to medical 
treatment. 

Case IV.— Nov. 15, 1887.— O. E. K., set. 33, banker, 
was referred to me by Dr. E. C. Seguin, who wrote : 
''He presents the occipito-cervical symptoms charac- 
teristic of eye-strain." 



^56 HEADACHE AND NEURALGIA. 

I found that Mr. K. had been fitted with cylindrical 
glasses by a distinguished ophthalmologist some years 
previously, but that they failed to relieve his eye-strain 
and headache. The glasses were + 1.25 D. c, axis 90°, 
both eyes. 

E. V = 1-^ + ; fl with + 0.50 D. c, axis 90°. 

L. V = H + ; II with + 0.50 D. c, axis 90°. 

He could still see f f with both eyes at once if 
+ 0.50 s. were added to the above glasses. 

Although there was insufficiency of the externi of 
1° to 2°, and his power of abduction was only 4°, about 
half what it ought to be, he rejected prisms as making 
him very uncomfortable. After much patient testing 
I found +0.75 D. c, ax. 90° both, to be the glasses 
which afforded him the most reUef. I therefore or- 
dered them for constant use. 

April 19, 1889. — Mr. K. says he has worn the glasses 
constantly since they were ordered, except when exer- 
cising in the open air, and that since he has been wear- 
ing them he has experienced entire relief of his occipito- 
cervical pain, except when he indulges in over-work, 
which easily brings it on. Recently he has felt a 
^^sort of nervousness " in and about his eyes. 

Upon testing his eyes again, it was found that they 
now accepted -f 1 D. c, ax. 90°, both. He was there- 
fore directed to have his glasses changed accordingly. 

The glasses which this patient had been trying to 
do his near work with before I saw him gave him very 
little relief, because they over- corrected his hyperme- 
tropic astigmatism. I corrected his manifest astigma- 
tism and the glasses were worn with relief from the 
first. It was necessary to change them for stronger 
ones because some of the hitherto latent hyperme- 
tropic astigmatism had been made manifest by the 
spontaneous relaxation of the ciliary muscles. 



CHAPTER II. 

HEADACHES DEPENDENT UPON IMPAIRED 
ACCOMMODATION. 

The most common form of impairec' accommoda- 
tion is that due to presbyopia, or old sight. The crys- 
talHne lens, like all the other tissues of the body, 
becomes harder as we grow older, and therefore less 
easily changed in shape by the action of the ciliary 
muscle. So that the presbyope is compelled to put 
forth additional effort in order to focalize upon the 
retina rays of light coming from near objects. The 
ciliary strain thus induced often causes headache, 
among other symptoms of asthenopia. The most 
familiar indication of presbyopia is a tendency to hold 
the book farther away from the eyes, and a blurring 
of fine print at any distance. When this occurs the 
cause is generally understood, and the patient cures 
himself by selecting glasses at an optician's. But 
when pain in the eyes and head, or slight blepharitis 
or conjunctivitis with sensitiveness to light, itching of 
the eye, etc., are the first symptoms that show them- 
selves, the patient is apt to apply for relief to the 
neurologist or ophthalmologist ; or, perhaps, first to 
his family physician, who refers him to the latter. 
We should not omit, then, to prescribe glasses for such 
patients, even although the power of accommodation 
still appears to be ample. Weak convex glasses usu- 
ally give the required relief, provided the patient can 
be persuaded to wear them notwithstanding his ability 



25S headaciit: AT^D KEITEALGIA. 

to read without them. Weak accommodation oc- 
casioned by paresis of the ciHary muscle should be 
supplemented by well-selected spectacles. Some have 
reported good results from the local use of a weak 
solution of eserine or pilocarpine in cases of weakness 
of the cihary muscle. 



CHAPTER III. 

HEADACHES DEPENDENT UPON INSUFFICIENCY OF THE 
EXTRINSIC OCULAR MUSCLES. 

A FRUITFUL source of headache is the want of pro- 
per balance, or of physiological equilibrium, of the mus- 
cles that move the eyes. Binocular single vision for 
distant objects should be maintained without effort. 
When one set of ocular muscles is relatively stronger 
than the opposing set an extra out-put of nervous 
energy is required to keep both eyes fixed upon the 
same object. There is a tendency of one eye to turn 
away from the object in the direction of the stronger 
muscle. An extra innervation has to be communicated 
to the weaker, opposing muscle. The eye -strain thus 
produced, with the multitude of consequent asthenopic 
and nervous symptoms, can only be relieved by restor- 
ing the ocular balance, and this is generally only to 
be accomplished by the use of prismatic spectacles, or 
by graduated tenotomy of the too-strong muscle. 

Case V.— Oct. 19, 1888.— Mrs. Dr. C. E. F., set. 28, 
has suffered, for many years, with severe pain in the 
back of the head and neck, tenderness over the mas- 
toids, and aching of the eyes. These pains have been 
aggravated by use of the eyes for reading and other 
near work, but she has suffered more or less from them 
most of the time. She has made it a rule never to 
give up as long as she could possibly help it, but some- 
times she has had to go to bed. She was kept under 
morphine for two or three days at one time, but as 



2G0 HEADACHE AND NEURALGIA. 

soon as the effects of the drug passed off the pains re- 
turned as bad as before. Mrs. F. has been wearing 
spectacles — tVs., which have improved her distant 
vision without reheving her headache. 

V = -gVo ; f|- with - 3.50 D., each eye. 

Hyperphoria 0°; esophoria 2° to 3°, the same in ac- 
commodation. Abduction 5°; adduction 28°, sursum- 
duction E. 1°, L. 1°. 

Ophthalmoscopic examination shows slight *^ ero- 
sion " at temporal edges of disks. 

Ordered— 3. D. Opi'ism 1|^°, base out, each eye, for 
all the time. 

April 17, 1889. — Mrs. F. says that since she has 
been wearing the glasses ordered last October she has 
had very little headache. After the first month's use 
of the glasses she has had scarcely any. 

In this case it was not sufficient to correct the error 
of refraction. It was also necessary to take the strain 
off her too weak externi, and this was done by com- 
bining prisms with her concave glasses. 

Case VI. -Jan. 21, 1887.— Miss Ada P., set. 36, has 
all her life been subject to neuralgic headaches. They 
always occurred when she got tired, or when anything 
caused the blood to rush to her head. In 1876, while 
attending the Centennial Exhibition at Philadelphia,, 
she noticed that after using her eyes continuously for 
two or three hours she was sure to have pain in the 
back of her head. Last winter a New York optician 
fitted her with glasses for distant vision which she wore 
with benefit. Last Christmas she sewed most of the 
day and in the evening read, and was attacked with a 
feeling of involuntary contraction in the eyes. Then 
pain came on and extended from her eyes to the root 
of her tongue, to her left ear, and to the back of her 
head and down her shoulders and back. She has been 



ON EYE STRAIN. / 201 

unable to use her eyes since without producing similar 
sensations. 

K- V = i H — ; emmetropic. 

L. V -= IS- - ; I!} with - ,V cyl., axis 180°. 

She is wearing, Rt.— -4V c, ax. 180°. 
Lft.- aVc, ax. 180°. 

No insufficiency for the distance. 

Esophoria in accommodation 13°. 

Abduction 6°; adduction 10°. 

January 22. — 

R. V = fl with - xk c, ax. 180°. 

L. V = fl with - tV c, ax. 180°, 

The above glasses were ordered for the distance. 

January 24. — Ordered for reading: 

Rt. + ji^ c, ax. 90°. 

Lft. + 4V c, ax. 90°, G prism 4°, base to nose. 

With these glasses the patient was directed to read 
twice daily, beginning with five minutes and increas- 
ing the task two minutes daily. 

February 7. — Miss P. is reading half an hour morn- 
ing and afternoon without disagreeable sensations. 

February 25.— Her tasks have reached an hour 
twice a day. As she had experienced no further 
trouble she was advised to stop her regular tasks and 
use her eyes as occasion might demand. 

I met her some time afterward, at the Manhattan 
Eye and Ear Hospital, where she brought a poor 
patient to see me, and she said that her glasses seemed 
to have banished the headaches permanently. 

Case VH.— February 23, 1886.— Lizzie V. S., aet. 19, 
complains of pain in her eyeballs and of *' heavy head- 
aches." She has been out of work for three months 
on account of ill-health caused, as she thinks, by strain- 
ing her eyes. 

V = -g¥o ; If ^^'ith - yV,^ each eye. 



2G2 HEADACHE AND NEURALGIA. 

Orthophoria; exophoria in accommodation, 14°. 

Ophthalmoscopic examination shows commencing 
staphyloma posticum in both eyes. 

Under atropia, E. V = |^ with - yV; L. V = f^ with 
— yV- Exophoria 4°. The right eye appears to turn 
out at times. 

Ordered — yi s., O prism 2°, base in, both eyes. 

May 28. — The patient states that she has worn the 
glasses constantly, for near and for far. She has had 
no headaches since wearing the glasses. She has had 
only one attack of pain in her eyeballs and that was 
not severe and lasted only a short time. 

I might multiply cases in which headaches had 
been totally, partially, or temporarily relieved by the 
use of prisms alone, or combined with spherical or 
cyhndrical glasses. But that is unnecessary. I have 
cited a sufficient number to show that in all cases of 
headache not relieved by other means prisms should 
be tried. Unfortunately the vast majority of patients 
who theoretically need prisma,tic spectacles and should 
be relieved by them are unable to wear them. The 
effects produced upon vision and upon the nervous 
system by them are so unpleasant that the glasses are 
quickly rejected. They change the shape of objects ; 
they make the floor or side-w^alk appear to approach 
the eyes or to recede from them, thus giving the 
wearer the sensation of walking up or down an inclined 
plane, while really walking on level ground; they make 
one end of the page that is being read narrower than 
the other end, or give it a slanting or oblique direction 
when it is being held squarely before the eyes ; or they 
produce faintness, dizziness or nausea. In such cases 
I have generally found it utterly useless to persuade 
the patient to continue to wear them. He is rarely 
able to overcome tliese disagreeable sensations by any 



/ 

ON EYE STRAIN. 2G3 

effort of the will. He rarely can compel himself to 
ignore fchem. When the ophthalmic sm^geon insists 
upon his continued attempts to do so he quietly solves 
the problem for himself by laying aside the glasses and 
doing the best he can without them, or by consulting 
another eye surgeon, who prescribes glasses without 
prisms. Not infrequently the patient accepts the pris- 
matic glasses when placed before his eyes in trial- 
frames, but rejects them after they have been made 
for him. 



CHAPTEE IV. 

GRADUATED TENOTOMY OF THE OCULAR MUSCLES. 

Where there is good reason to believe that the 
headache is due to insufficiency of the ocular muscles 
(heterophoria), and prismatic spectacles are rejected, 
there only remains the resort to graduated tenotomy 
of the stronger, opposing muscle, so as to restore, as 
perfectly as possible^ the condition of physiological 
equilibrium (orthophoria). I propose to close this 
chapter by relating a few cases treated after this 
method. 

Case YIII. — Miss Alice A., age 27, consulted me on 
June 13, 1887. After using her eyes she has headache. 
She cannot look steadily at anything. Her father 
died insane. His mother, sister and cousin also were 
insane. She has a cousin in an insane asylum. She 
broke down after a hard winter's work, and has since 
had headache almost without intermission. She has 
a feeling in the back of the head and neck as if her 
head were being drawn back. She also has a 'h'ump- 
ing headache " all over the top of her head. The jar 
of walking hurts her. Sometimes she feels *^ sort of 
lost," as if she did not know anything. For many 
years she has observ^ed that her left pupil is a little 
smaller than the right. E. V = i H — ; Hm ^V ; L. Y 
= llj — ; Hm jV- Spectacles + 4^0 were prescribed, 
and she was put upon increasing reading tasks. 

August 20. — She now reads four hours a day with 
her glasses, Exophoria 12°; abduction 15° She has 



ON EYE STRAIN. 205 

single binocular vision in reading. Tenotomy of left 
extermts, leaving orthophoria. June 21. — The head- 
ache she had yesterday before the operation was for- 
gotten after it, and has not come on since. 

August 27. — She has done her usual work as gov- 
erness since last here. She has experienced none of 
the *^ drawing feeling "in the back of the head and 
neck, but she has a tired feeling. Orthophoria ; ab- 
duction 10°; adduction 12°. 

Case IX. — Wm. H., age 44, married, merchant, 
came May 23, 1887. Mr. H. was troubled with headache 
all his life, and supposed it was due to indigestion until 
three years ago, when it was suggested that it might 
be due to eye-strain. He then went to Dr. Stevens, 
who gave him glasses and exercised his ocular muscles 
with prisms. The glasses relieved his headaches ; but 
recently he has had a relapse. If he reads at all with- 
out his glasses, or even three minutes with them, 
^^ his head is wrong," and he becomes intensely sick 
all over, but does not vomit. His general health is 
good, his bowels regular ; he sleeps well. He never 
had any disease except malaria. E. V = f^ ; Hm -^ ; 
L. V = |g - ; 11 + with + j\ c, ax. 90°. Esophoria 
3° to 6°; in accommodation 15°; no hyperphoria ; ab- 
duction 2°; adduction 23°; sursumduction, E. 0°, L. 0°. 
His glasses are prisms, base out. May 24. — Tenotomy 
of left internus, leaving orthophoria. 

September 20.— Mr. M. thinks he was helped very 
much by the operation, but is not entirely relieved. 

September 21.— Esophoria 6°; abduction 2°; adduc- 
tion 22°; tenotomy of right internus. 

October 10. — No headaches since the last operation; 
wears no glasses, and uses his eyes with comfort ; 
orthophoria. 

Case X.— Dr. W. S. K., age 32, consulted Dr. C. 



266 HEADACHE AND NEURALGIA. 

R. Agnew on April 25, 1877. He stated that he had 
no trouble with his eyes until September, 1876, when 
neuralgic pains about the root of his nose set in while 
reading. There was a f eehng of severe tension over his 
brow while reading. He used belladonna ointment 
over his brows until his accommodation grew weak, 
and he had to give up reading altogether. He then 
became excessively nervous all over. He consulted 
Soelberg Wells, who dilated his pupils and found his 
fundus normal, but that he had Ht 3V each eye. He 
has worn + -3V constantly since. 

Dr. K. says his eyes first ^* broke down'^ while 
working all day with the ophthalmoscope and micro- 
scope, and then reading late at night. At Christmas 
he observed that he would become worse when the 
gas was lighted. He went to church on one occasion, 
and the bright light caused great infra-orbital neural- 
gia and neuralgia of the third division of the fifth 
nerve. This has been confirmed a dozen times. Read- 
ing or walking in bright sunhght invariably brings 
on pain in the inferior maxillaiy region, the pain being 
more especially referred to the front teeth below. His 
teeth were never tender in mastication, and he has 
only one carious tooth, the first molar on. the right 
side, and that is well filled. He is troubled with spasms 
about his internal canthi when he lies down. His 
digestion seems to be good. Never venereal disease. 
His father was rheumatic and perhaps gouty. He says 
he is as nervous as a hysterical woman. He jerks and 
starts when he goes off to sleep. He suffers from sci- 
atica of the left hip, but he attributes that to a fall 
from a horse when a boy. 

y = l^ each with + ^. No insufficiency. Oph- 
thalmoscopic examination gives him excruciating pain, 
lasting twenty -four hours or less. 



ON EYE STRAIN. 267 

The patient was referred to Dr. E. C. Seguin for an 
opinion. Dr. Seguin wrote : 

*' April 25, 187T, Dr. K.'s case has seemed very in- 
teresting to me. I am disposed to look upon his hyper- 
aesthesia (face and limbs) as due primarily to insuffi- 
cient nutrition. He has worked hai'd and used a diet, 
which I look upon as perfectly fitted to develop anaemia 
and neuralgia. I would suggest beefsteak and roast 
meats twice a day, ale or claret for dinner, and not 
much starchy food. Thompson's solution of phos- 
phorus may also do good, and relief may be had by the 
positive pole of the galvanic battery. I don't find the 
usual symptoms of asthenopia." 

April 26. — Hm ^ each. Cooper, and Wells, and 
Purvis, of London, all examined his eyes under atro- 
pine and found that his Ht was + gV- April 19, 1887. 
— The patient returns to me with a letter from Dr. A. 
W. Calhoun, of Atlanta. He stated that he got no 
relief from his glasses, and finally discarded them alto- 
gether. Since ten years ago he has suffered agony 
every hour that he has been awake, and he has been 
kept awake many nights with pain through the tem- 
ples, through the roots of the nose, and through the 
teeth and malar bones. The main pain is through the 
malar bones and nose. No pain in top of head or in 
occipital region. E. V = |f — ; f f with + A ; L. V 
= M ~ ; fo with + ^V- No hyperphoria ; esophoria 
2°; abduction 2°; adduction 12°. May 7.— Esophoria 
4°; in accommodation 0°; hyperphoria, R. 1°; abduction 
4°; adduction 13°; sursumduction, R. 0°, L. 0°. The 
patient was now referred to a physician skilled in dis- 
eases of the nose, who found that he had a deviated 
septum and operated upon it. He also operated upon 
his hypertrophied turbinated bone, but without much 
apparent benefit. May 12. — Tenotomy of right inter- 



268 HEADACHE AND NEURALGIA. 

nuSj leaving orthophoria, with abduction 8°; as found 
on testing half an hour after the operation. May 13. 
— Went to bed last night with a freedom from pain 
which he has not experienced for years. Esophoria 4° ; 
abduction 8°. May 21. — Orthophoria: abduction Y°; 
adduction 19°; much improved. April 2, 1888. — The 
patient writes, *' I have done a hard winter's work in 
the college and with my practice, and my eyes have 
held up very well." 

Case XI. — Nellie C, age 20, came to me at the 
Manhattan Eye and Ear Hospital on February 17, 1888. 
For several years she has suffered from severe head- 
aches, which occurred almost every other day. The 
pain was principally across the forehead, and very sel- 
dom extended to the back of her head. The headaches 
last two or three hours, and are usually brought on by 
reading, but sometimes occur without any exciting 
cause. She has a great deal of facial neuralgia also. 
Within the past seven months she becomes sleepy 
after using her eyes in reading or sev/ing any length 
of time. She is very often taken with fainting spells, 
fainting away and becoming quite unconscious. Eight 
days ago she had two or three such fainting spells. 
The first fainting spell w^as about four years ago, when 
she was attacked with it while grinding coffee. She 
has usually had these spells not more than once or 
twice a month. She was ill during the whole of last 
summer. She was cashier in a store at the time and 
got very weak. 

R.V = f^; ifw.+J^. L.V = H;Em. Hyper- 
phoria, E. 3°; esophoria 2°; abduction 3°; adduction 
16°; sursumduction, E. 4°, L. 5°. February 25. — 
Divided the right superior rectus, leaving the hyper- 
phoria exactly corrected. The patient fainted twice 
during the operation. February 26. — She had some 



ON EYE STRAIN. ' 209 

headache after reading this morning. February 27. — 
Orthophoria ; abduction 6°; adduction 16°; sursum- 
duction, E. 3°, L. 3°. March 2.— Orthophoria. Sep- 
tember 14, 1888. — The patient states that she has had 
no headaches or fainting spells since the operation, a 
period of nearly a year. 

K. V = II - ; U with + "^Vc, ax. 90°. L. V = 
f ^ ; Hm^V- Orthophoria; abduction 5°; adduction 
16°; sursumduction, R. 3°, L. 3°. 

May 11, 1889. — I saw this patient at the Manhattan 
Eye and Ear Hospital about a week ago. She came to 
report that she had had no headaches or fainting spells 
since I last saw her, and that she considered herself 
permanently cured. 

Case XII.— Rev. F. D. G., age 30, missionary to 
China, was referred to me by Dr. E. C. Seguin, with 
the following letter, dated December 27, 1887 : *^ Rev. 
Mr. G. has congestive symptoms about the head and a 
degree of nervous probtration — now relieved. Since 
eight years he has noticed occipital pain and distress 
on the prolonged use of his eyes, symptoms suggestive 
to me of muscular insufficiency in accommodation. 
He has good vision, and to me, his eyes are about 
emmetropic." 

Upon testing Mr. G., I found : R. V == t| ; E. L. 
V = f ^ ; Hm 0.25 D.; hyperphoria, L. 1°; esophoria 
1°; exophoria in accommodation '4°; abduction 4°; 
adduction 14°; sursumduction, R. 3°; L. 2^. Decem- 
ber 28.— Under homatropine : R. V = ff with + 0.50 
D.; K V = Hwith + lD.; hyperphoria, L. |; ab- 
duction 7°. 

Ophthalmoscopic examination shows physiological 
excavation of both discs and pulsation of the retinal 
veins in both eyes. There was no lesion of either eye 
except a small white spot just above the right macula. 



270 HEADACHE AKD NEUEALGIA. 

December 30. — Hyperphoria, Left 1°; tenotomy of the 
left superior rectus, sHghtly OYer-correcting the hyper- 
phoria. January 3, 1888. — Abduction Y°. January 6. 
— Esophoria 2°; hyperphoria, L. ^; abduction 5°; 
adduction 18°; sursumduction, E. 4°; L. 3°. He was 
instructed to exercise his interni daily with prisms. 
January 9. — Abduction 1°; adduction 50°; esophoria 
6°; in accommodation 6°. January 13. — Abduction 5°; 
esophoria 2° to 5°. January 20. — Abduction '7°; hyper- 
phoria, L. 1°; ordered glasses Et. + 0.25 D., Lft. + 
0.25 D. O l°j t)ase down, to wear all the time. Janu- 
ary 27. — Abduction 6°; hyperphoria, L. 1°. He said 
he had experienced relief from the use of the glasses, 
although reading with them for three hours brought 
on occipital headache, and after continuing the use of 
them four hours longer the headache was as bad as 
ever. 

Tenotomy of Right Inferior Rectus, leaving a sHght 
over-correction. February 10, 1888. — He reported that 
his headache had been better and that he read six or 
seven hours the day before without headache. The 
tests show orthophoria ; ordered glasses + 0.25 D., 
both eyes, without any prism. March 15. — The patient 
says his head symptoms have almost disappeared. For 
a month or more the eyes have been '^ sore to the 
touch," and more or less red, especially on rising in 
the morning. The redness disappears after a while 
He has had these inflammatory symptoms since wear- 
ing the glasses. He was now advised to stop wearing 
the glasses, and the camphor and borax wash was pre- 
scribed for him. Examination showed orthophoria. 
June 15. — I met the patient outside my office and he 
informed me that he had no special trouble with his 
head, although he had been hard at work for some 
months, and that he anticipated a speedy return to his 



ON EYE STRAIN. r " 271 

missionary duties. October 2. — Orthophoria ; eso- 
phoria in accommodation 6°; abduction 5°; adduction 
30°; sursumduction, K. 2°; L. 2°. Mr. G. was unavoid- 
ably detained in this country. He considers himself 
greatly benefited by the tenotomies, and is doing full 
work with his -i- 0.25 D. 

May 11, 1889. — Mr. G. states that he has not been 
troubled by any head symptoms since I saw him and 
works as comfortably as ever. Orthophoria ; adduc- 
tion 7°. He is about to return to his work in China. 



INDEX. 



Brain, localization of the 
Dreams, 209 

cerebration of, difficulty of 
controlling the, 215 

classification of, difficulty at- 
tending the, 215 

comparison of, to insanity, 
215 

composition of, 209 

conceptions of, rapid evolu- 
tion of, 217 

difference between, and wak- 
ing thought, 215 

emotions of, less hurt fuithan 
those of the waking state, 
218 

indigestion as a cause of, 
210 

impressions which give rise 
to, 209 

malposition as a cause of, 
210 

reduction of the feeling of 
personality during dreams, 
218 

"supernatural agency" in, 
210 
Electro-compression of the caro- 
tids, mode of executing, 28 
Headache, anaemic, 22 

alcohol in, 24 

diet in, 25 

elevation of lower extremi- 
ties, 24 

horizontal position in, 25 



action of remedies upon, 228 
Headache, anajmic, nitrite of 
amyl in, 24 

nitrous oxide in, 25 

opium in, 24 

symptoms of, 22 

treatment of, 24 

cases illustrative of different 
phases of, 56 
Headache, congestive, 26 

blisters in, 36 

carotid compression in, 27 

causation of, 26 

cold to the head in, 34 

dry-cupping in, 36 

electro-compression of the 
carotids in, 28 

epistaxis, artificial in, 35 

galvanic current in, 36 

hot baths in, 32 

hot water to feet in, 32 

ice- water cap in, 32 

symptoms of, 26 

treatment of, 27 
Headache, nervous, 38 

antipyrene in, 42 

bromides in, 41 

causation of, 40 

chloral in, 41 

compression of scalp and hot- 
water bag in, 41 

definition of, 38 

hyoscyamus in, 41 

morphine in, 41 

seclusion in, 43 



274 



INDEX. 



Headache, nervous, sleep in, 43 

symptoms of, 39 

treatment of, 40 
Headache, organic, 53 

causation of, 58 

chloral in, 55 

diagnosis of, 53 

iodide of potassium in, 54 

morpliine in, 54 

symptoms of, 53 

treatment of, 53 
Headache, sympathetic (bilious 
headache), 47 

causation of, 47 

intolerance of the stomach to 
remedies in, 50 
Headache, symptoms of, 48 

treatment, 49 
Headache, toxic, 44 

causation of, 44 

defective ventilation as a 
cause of, 45 

lead poisoning as a cause of, 
45 

pilocarpin in, 46 

purgatives in, 46 

treatment of, 45 

Turkish bath in, 46 

uraemic intoxication as a 
cause of, 45 
Head-pains, 15 

classification of, 30 

dura mater in, 19 

Erb on, 18 

mechanism of, 15 

Niemeyer on, 17 

Prus on, 19 

Symondson, 16 
Insomnia, 199 

classification of, 199 

idiopathic, 301 

secondary, 306 

treatmenl.of, 333 



Insomnia, weight, variation of 

in, 333 
Neuralgia, general considera- 
tions on, 63 

aniesthesia in, 65 

characteristics of, 63 

classification of, 66 

debility in, 63 

hyperassthesia in, 65 

points apophysaire, 65 

puncta dolorosa of, 64 

spasms, muscular in, 65 

vaso-motor disturbances in, 
65 
Neuralgia, forms of, 66 

cervico-brachial, 71 

cervico-occipital, 71 

coccygodynea, 76 

crural, 73 

dorso-intercostal, 74 

lumbar, 73 

lumbo-abdominal, 73 

mastodynia, 77 

muscular, 77 

osteal, 140 

periosteal, 140 

plantar, 75 

sciatic, 74 
Neuralgia, trigeminal, 67 

(a) supra-orbital, or oph- 
thalmic neuralgia, 69 

(b) supra-maxillary neural- 
gia, 70 

(c) infra-maxillary neural- 
gia, 70 

Neuralgia, summary 

causation, 79 

diagnosis, 83 

pathology, 84 

prognosis, 86 
Neuralgia, treatment of, 88 

aconitia in, 139 

arsenic in, 133 



INDEX. 



275 



Neuralgia, atropine, 128 

batiis in, 135 

bromide of potassium, 131 

cantharides in, 133 

cases illustrative of the effi- 
cacy of local measures, 100 

chloral in, 130 

chloroform in, 129 

cocaine, introduction of into 
the skin about the face, 94 

electricity in, 119 

freezing, local in, 135 

heat in, 140 

iodine in, 133 

iron in, 133 

local medication of nerves, 93 

morphine in, 126 

narcotics in, 125 

ointments in, manner of em- 
ploying the, 128 

phosphorus in, 132 

pressure and electricity in, 
121 

quinine in, 132 

remedies adapted to local 
medication, 93 

remedies, endermic use of in 
neuralgia. 111 

remedies, introduction of in- 
to the integument by the 
aid of galvanism, 95 

remedies, prolongation of the 
local action of, 97 

strychnine in, 133 

surgical expedients in, 138 

turpentine in, 133 

valerian in, 133 

veratrine in, 129 



Neuralgia, zinc in, 133 
Sleep, 187 

carotid circulation in, 187 

cerebro-spinal fluid, increase 
of within the skull in cere- 
bral anaimia, experiments 
of Nounym and Schreiber, 
194 

definition of, 187 

derangements of in painful 
affections, 187 

essential factors of, 198 

excretion of phosphates and 
sulphates diminished dur- 
ing, 197 

physiology of, 188 

Schiff's experiments on, 192 

urine composition modified 
by, 196 
Somnolence, morbid, 219 

cases illustrative of, 220 
Spinal irritation, 145 

cases illustrating the efficacy 
of local medication of the 
cord, 161 

diagnosis of, 149 

local medication of the cord, 
154 

local medication of the cord, 
author's method of execute 
ing the, 158 

pathologj^ of, 148 

symptoms of, 145 

treatment, 151 
Spinal irritation due to shock, 169 

cases, 171 

symptoms of, 170 



APPENDIX. 

Eye Strain, a Cause of Headache 



345 




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